Controlled-release otic structure modulating and innate immune system modulating compositions and methods for the treatment of otic disorders

ABSTRACT

Disclosed herein are compositions and methods for the treatment of otic disorders with otic structure modulating compositions administered locally to an individual afflicted with an otic disorder, through direct application of these compositions and compositions onto or via perfusion into the targeted auris structure(s).

CROSS-REFERENCE

This application claims the benefit of U.S. Provisional Application No.61/082,450, filed 21 Jul. 2008; U.S. Provisional Application No.61/091,205, filed 22 Aug. 2008; U.S. Provisional Application No.61/094,384, filed 4 Sep. 2008; U.S. Provisional Application No.61/101,112, filed 29 Sep. 2008; U.S. Provisional Application No.61/108,845, filed 27 Oct. 2008; U.S. Provisional Application No.61/140,033, filed 22 Dec. 2008; U.S. Provisional Application No.61/156,771, filed 2 Mar. 2009; and U.S. Provisional Application No.61/091,200, filed 22 Aug. 2008; all of which are incorporated byreference herein in their entirety.

BACKGROUND OF THE INVENTION

Vertebrates have a pair of ears, placed symmetrically on opposite sidesof the head. The ear serves as both the sense organ that detects soundand the organ that maintains balance and body position. The ear isgenerally divided into three portions: the outer ear, auris media (ormiddle ear) and the auris interna (or inner ear).

SUMMARY OF THE INVENTION

Described herein, in certain embodiments, are compositions,compositions, manufacturing methods, therapeutic methods, uses, kits,and delivery devices for the controlled-release of an otic structuremodulating agent or innate immune system modulating agent to at leastone structure or region of the ear. Disclosed herein, in certainembodiments, are controlled-release compositions for delivering an oticstructure modulating agent or innate immune system modulating agent tothe ear. In some embodiments, the target portion of the ear is themiddle ear (or auris media). In some embodiments, the target portion ofthe ear is the inner ear (or auris interna). In other embodiments, thetarget portion of the ear is both the auris media and the auris interna.In some embodiments, the controlled-release compositions furthercomprise a rapid or immediate release component for delivering an oticstructure modulating agent or innate immune system modulating agent tothe targeted auris structure. All compositions comprise excipients thatare auris-acceptable.

Also disclosed herein, in certain embodiments, are compositions anddevices for the treatment of otic disorders, said compositions anddevices comprising an otic structure modulating agent or innate immunesystem modulating agent. Further disclosed herein, in certainembodiments, are methods for the treatment of otic disorders byadministration of a controlled-release composition comprising an oticstructure modulating agent or innate immune system modulating agent toan individual in need thereof. In some embodiments, the otic disorder isotitis externa, otitis media, mastoiditis, sensorineural hearing loss,ototoxicity, endolymphatic hydrops, labyrinthitis, Meniere's disease,Meniere's syndrome, microvascular compression syndrome, vestibularneuronitis, acoustic trauma, presbycusis, cholesteatoma, otosclerosis,Scheibe syndrome, Mondini-Michelle syndrome, Waardenburg's syndrome,Michel syndrome, Alexander's ear deformity, hypertelorism, Jervell-LangeNielson syndrome, Refsum's syndrome, Usher's syndrome, or combinationsthereof. In some embodiments, the otic disorder is otitis externa,otitis media, mastoiditis, AIED, Ramsay Hunt's, reperfusion injury,labyrinthitis ossificans or combinations thereof.

The auris compositions and therapeutic methods described herein havenumerous advantages that overcome the previously-unrecognizedlimitations of compositions and therapeutic methods described in priorart.

Sterility

The environment of the inner ear is an isolated environment. Theendolymph and the perilymph are static fluids and are not in contiguouscontact with the circulatory system. The blood-labyrinth-barrier (BLB),which includes a blood-endolymph barrier and a blood-perilymph barrier,consists of tight junctions between specialized epithelial cells in thelabyrinth spaces (i.e., the vestibular and cochlear spaces). Thepresence of the BLB limits delivery of active agents (e.g., oticstructure modulating agent or innate immune system modulating agents) tothe isolated microenvironment of the inner ear. Auris hair cells arebathed in endolymphatic or perilymphatic fluids and cochlear recyclingof potassium ions is important for hair cell function. When the innerear is infected, there is an influx of leukocytes and/or immunoglobulins(e.g. in response to a microbial infection) into the endolymph and/orthe perilymph and the ionic composition of inner ear fluids is upset bythe influx of leukocytes and/or immunoglobulins. In certain instances, achange in the ionic composition of inner ear fluids results in hearingloss, loss of balance and/or ossification of auditory structures. Incertain instances, trace amounts of pyrogens and/or microbes triggerinfections and related physiological changes in the isolatedmicroenvironment of the inner ear.

Due to the susceptibility of the inner ear to infections, auriscompositions require a level of sterility that has not been recognizedhitherto in prior art. Provided herein are auris compositions that aresterilized with stringent sterility requirements and are suitable foradministration to the middle and/or inner ear. In some embodiments, theauris compatible compositions described herein are substantially free ofpyrogens and/or microbes.

Compatibility with Inner Ear Environment

Described herein are otic compositions with an ionic balance that iscompatible with the perilymph and/or the endolymph and does not causeany change in cochlear potential. In specific embodiments,osmolarity/osmolality of the present compositions is adjusted, forexample, by the use of appropriate salt concentrations (e.g.,concentration of sodium salts) or the use of tonicity agents that renderthe compositions endolymph-compatible and/or perilymph-compatible (i.e.isotonic with the endolymph and/or perilymph). In some instances, theendolymph-compatible and/or perilymph-compatible compositions describedherein cause minimal disturbance to the environment of the inner ear andcause minimum discomfort (e.g., vertigo) to a subject (e.g., a human)upon administration. Further, the compositions comprise polymers thatare biodegradable and/or dispersible, and/or otherwise non-toxic to theinner ear environment. In some embodiments, the compositions describedherein are free of preservatives and cause minimal disturbance (e.g.,change in pH or osmolarity, irritation) in auditory structures. In someembodiments, the compositions described herein comprise antioxidantsthat are non-irritating and/or non-toxic to otic structures.

Dosing Frequency

The current standard of care for auris compositions requires multipleadministrations of drops or injections (e.g. intratympanic injections)over several days (e.g., up to two weeks), including schedules ofreceiving multiple injections per day. In some embodiments, auriscompositions described herein are controlled-release compositions andare administered at reduced dosing frequency compared to the currentstandard of care. In certain instances, when an auris composition isadministered via intratympanic injection, a reduced frequency ofadministration alleviates discomfort caused by multiple intratympanicinjections in individuals undergoing treatment for a middle and/or innerear disease, disorder or condition. In certain instances, a reducedfrequency of administration of intratympanic injections reduces the riskof permanent damage (e.g., perforation) to the tympanic membrane. Thecompositions described herein provide a constant, sustained, extended,delayed or pulsatile rate of release of an active agent into the innerear environment and thus avoid any variability in drug exposure intreatment of otic disorders.

Therapeutic Index

Auris compositions described herein are administered into the ear canal,or in the vestibule of the ear. In some embodiments, access to thevestibular and cochlear apparatus occurs through the auris media (e.g.,the round window membrane, the oval window/stapes footplate, the annularligament and through the otic capsule/temporal bone). Oticadministration of the compositions described herein avoids toxicityassociated with systemic administration (e.g., hepatotoxicity,cardiotoxicity, gastrointestinal side effects, renal toxicity) of theactive agents. In some instances, localized administration in the earallows an active agent to reach a target (e.g., the inner ear) in theabsence of systemic accumulation of the active agent. In some instances,local administration to the ear provides a higher therapeutic index foran active agent that would otherwise have dose-limiting systemictoxicity.

Prevention of Drainage into Eustachian Tube

In some instances, a disadvantage of liquid compositions is theirpropensity to drip into the eustachian tube and cause rapid clearance ofthe composition from the inner ear. Provided herein, in certainembodiments, are auris compositions comprising polymers that gel at bodytemperature and remain in contact with the target auditory surfaces(e.g., the round window) for extended periods of time. In someembodiments, the compositions further comprise a mucoadhesive thatallows the compositions to adhere to otic mucosal surfaces. In someinstances, the auris compositions described herein avoid attenuation oftherapeutic benefit due to drainage or leakage of active agents via theeustachian tube.

DESCRIPTION OF CERTAIN EMBODIMENTS

Described herein, in certain embodiments, are controlled-releasecompositions and devices for treating otic disorders comprising atherapeutically-effective amount of an otic structure modulating agentor innate immune system modulating agent, a controlled-releaseauris-acceptable excipient and an auris-acceptable vehicle. In oneaspect, the controlled-release auris-acceptable excipient is chosen froman auris-acceptable polymer, an auris-acceptable viscosity enhancingagent, an auris-acceptable gel, an auris-acceptable paint, anauris-acceptable foam, an auris-acceptable microsphere or microparticle,an auris-acceptable hydrogel, an auris-acceptable in situ forming spongymaterial, an auris-acceptable actinic radiation curable gel, anauris-acceptable liposome, an auris-acceptable nanocapsule ornanosphere, an auris-acceptable thermoreversible gel or combinationsthereof. In further embodiments, the auris-acceptable viscosityenhancing agent is a cellulose, a cellulose ether, alginate,polyvinylpyrrolidone, a gum, a cellulosic polymer or combinationsthereof. In yet another embodiment, the auris-acceptable viscosityenhancing agent is present in an amount sufficient to provide aviscosity of between about 1000 to about 1,000,000 centipoise. In stillanother aspect, the auris-acceptable viscosity enhancing agent ispresent in an amount sufficient to provide a viscosity of between about50,000 to about 1,000,000 centipoise.

In some embodiments, the compositions disclosed herein are formulatedfor a pH that ensures that they are compatible with the targeted aurisstructure. In some embodiments, the compositions disclosed herein areformulated for a practical osmolality and/or osmolarity that ensuresthat homeostasis of the target auris structure is maintained. Aperilymph-suitable osmolarity/osmolality is a practicalosmolarity/osmolality that maintains the homeostasis of the target aurisstructure during administration of the pharmaceutical compositionsdescribed herein.

For example, the osmolarity of the perilymph is between about 270-300mOsm/L and the compositions described herein are optionally formulatedto provide a practical osmolarity of about 150 to about 1000 mOsm/L. Incertain embodiments, the compositions described herein provide apractical osmolarity within about 150 to about 500 mOsm/L at the targetsite of action (e.g., the inner ear and/or the perilymph and/or theendolymph). In certain embodiments, the compositions described hereinprovide a practical osmolarity within about 200 to about 400 mOsm/L atthe target site of action (e.g., the inner ear and/or the perilymphand/or the endolymph). In certain embodiments, the compositionsdescribed herein provide a practical osmolarity within about 250 toabout 320 mOsm/L at the target site of action (e.g., the inner earand/or the perilymph and/or the endolymph). In certain embodiments, thecompositions described herein provide a perilymph-suitable osmolaritywithin about 150 to about 500 mOsm/L, about 200 to about 400 mOsm/L orabout 250 to about 320 mOsm/L at the target site of action (e.g., theinner ear and/or the perilymph and/or the endolymph). In certainembodiments, the compositions described herein provide aperilymph-suitable osmolality within about 150 to about 500 mOsm/kg,about 200 to about 400 mOsm/kg or about 250 to about 320 mOsm/kg at thetarget site of action (e.g., the inner ear and/or the perilymph and/orthe endolymph). Similarly, the pH of the perilymph is about 7.2-7.4, andthe pH of the present compositions is formulated (e.g., with the use ofbuffers) to provide a perilymph-suitable pH of about 5.5 to about 9.0,about 6.0 to about 8.0 or about 7.0 to about 7.6. In certainembodiments, the pH of the compositions is within about 6.0 to about7.6. In certain instances, the pH of the endolymph is about 7.2-7.9, andthe pH of the present compositions is formulated (e.g., with the use ofbuffers) to be within about 5.5 to about 9.0, within about 6.5 to about8.0 or within about 7.0 to about 7.6.

In some aspects, the controlled-release auris-acceptable excipient isbiodegradable and/or bioeliminated (e.g., degraded and/or eliminatedthrough urine, feces or other routes of elimination). In another aspect,the controlled-release composition further comprises an auris-acceptablemucoadhesive, an auris-acceptable penetration enhancer or anauris-acceptable bioadhesive.

In one aspect, the controlled-release composition is delivered using adrug delivery device, which is a needle and syringe, a pump, amicroinjection device, and in situ forming spongy material orcombinations thereof. In some embodiments, the otic structure modulatingagent or innate immune system modulating agent of the controlled-releasecomposition has limited or no systemic release, is toxic whenadministered systemically, has poor pK characteristics, or combinationsthereof.

In some embodiments, the otic structure modulating agent is an oticstructure enhancing agent (e.g., a molecular component of an oticstructure). In some embodiments, the otic structure enhancing agent isactin, aggrecan, chondroitin, collagen, decorin, dermatan sulfate,elastin, fibrinogen, fibronectin, fimbrin, glial fibrillary acidicprotein, heparan sulfate, hyaluronic acid, keratin, laminin, nestin,NF-L, NF-M, NF—H, NF66, peripherin, α-tubulin, β-tubulin, villin,vimentin, whirlin, or combinations thereof.

In some embodiments, the otic structure modulating agent is an oticstructure degrading agent. In some embodiments, the otic structuredegrading agent degrades bone. In some embodiments, the otic structuredegrading agent degrades cartilage. In some embodiments, the oticstructure degrading agent degrades a neuron. In some embodiments, theotic structure degrading agent degrades a membrane (e.g., a tympanicmembrane). In some embodiments, the otic structure degrading agentdegrades endolymph. In some embodiments, the otic structure degradingagent degrades perilymph. In some embodiments, the otic structuredegrading agent degrades liquor puris (i.e., pus).

In some embodiments, the otic structure modulating agent is an oticstructure degrading agent. In some embodiments, the otic structuredegrading agent is an alcohol, an alkanol, an essential oil, a fattyacid, a glycol, laurocapram, a pyrrolidone, a sulfoxide, a surfactant,an enzyme, or a combination thereof. In some embodiments, the enzyme isa protease, a glycosidase, protease, a glycosidase, an actinase, acaseinase, a chondroitinase, a collagenase, a dermatanase, an elastase,a gelatinase, a heparanase, a hyaluronidase, a keratinase, a lipase, ametalloproteinase (e.g. matrix metalloproteinase), a staphylokinase, astreptokinase, chymotrypsin, endopeptidase V8, trypsin, thermolysin,pepsin, plasmin, or combinations thereof. In some embodiments, the oticstructure modulating agent is a modulator of bone remodeling. In someembodiments, the modulator of bone remodeling is a modulator ofosteoblasts or osteoclasts, including but not limited to, hormones;bisphosphonates; matrix metalloproteinase inhibitors; an adenylylcyclase (AC) modulators; protease inhibitors; modulators of tartarateresistant acid phosphatase (TRACP); estrogen receptor modulators; PPAR γmodulators; HMG-CoA reductase inhibitors; statins; carbonic anhydraseinhibitors; modulators of the receptor activator of nuclear κB ligand(RANKL); COX-2 inhibitors; inhibitors of protein prenylation;5-lipoxygenase inhibitors; inhibitors of TNF; inhibitors ofleukotrienes; cytokine modulators; inhibitors of TSG-6, modulators ofTGF β; nitiric oxide synthase inhibitors; acetylcysteine; modulators ofaromatases; and strontium-based compounds as disclosed inWO/2008/027880, which is incorporated by reference herein.

In some embodiments, the otic structure modulating agent is an oticstructure enhancing agent. In some embodiments, the otic structureenhancing agent rebuilds or supplements bone. In some embodiments, theotic structure enhancing agent rebuilds or supplements cartilage. Insome embodiments, the otic structure enhancing agent rebuilds orsupplements a membrane (e.g., a tympanic membrane). In some embodiments,the otic structure enhancing agent rebuilds or supplements endolymph. Insome embodiments, the otic structure enhancing agent rebuilds orsupplements perilymph.

In some embodiments, the otic structure modulating agent is an oticstructure enhancing agent. In some embodiments, the otic structureenhancing agent is actin, aggrecan, chondroitin, collagen, decorin,dermatan sulfate, elastin, fibrinogen, fibronectin, fimbrin, glialfibrillary acidic protein, heparan sulfate, hyaluronic acid, keratin,laminin, nestin, NF-L, NF-M, NF—H, NF66, peripherin, α-tubulin,β-tubulin, villin, vimentin, whirlin, or combinations thereof.

In some embodiments, the innate immune system modulating agent is acomplement cascade modulating agent and/or an anaphylatoxin modulator.In some embodiments, the innate immune system modulating agent is acomplement cascade antagonist and/or an anaphylatoxin antagonist. Insome embodiments, the innate immune system modulating agent is acomplement cascade agonist and/or an anaphylatoxin agonist.

In some embodiments, the innate immune system modulating agent is CHIPS,PMX53, PMX205, PMX273, PMX201, PMX218, C089, L-156,602, C5aRAM, C5aRAD,PR226-MAP, PL37-MAP, SB-290157, GR-2II, AGIIa, AGIIb-1, AR-2IIa,AR-2IIb, AR-2IIc, AR-2IId, CVF, CVF, humanized CVF, rC3, HC3-1496,HC3-1496-2, HC3-1496-3, HC3-1496-4, HC3-1496/1617, HC3-1496-8,HC3-1496-9, HC3-1496-10, HC3-1496-11, HC3-1496-12, HC3-1496-13,HC3-1496-14, HC3-1496-15, HC3-1496-16, HC3-1496-17, complement component1 inhibitor, dextran sulfate, complement component 1q receptor, C1qinhibitor, decorin, CSPG, CBP2, complement receptor 1, sCR1, APT070,TP10, TP20, sCR1[desLHR-A]), sCR1-SLe^(x), Crry, Crry-Ig, a fucan, BS8,complestatin, Ecb, Efb, compstatin, rosmarinic acid, CRIT, CRIT-H17,glycyrrhetinic acid, an anti-complement component 5 (C5) murinemonoclonal antibody, pexelizumab, an anti-C5 murine single-chainantibody, K76, TKIXc, K76 COOH, SCIN, SCIN-B, SCIN-C, CD55, sCD55, CD59,sCD59, a CD59/CD55 fusion protein, a CD55/MCP fusion protein, BCX-1470,FUT-175, Factor I, MCP, sMCP, heparin, LU 51198, clusterin, vitronectin,an anti-properdin antibody, SB 290157(N2-((2,2-diphenylethoxy)acetyl)arginine), anti-MIF antibody, metformin,ISO-1,2-[(4-hydroxybenzylidene)amino]-3(1H-indol-3-yl)propionic acidmethyl ester, NAPQI, AVP-28225, or combinations thereof.

Also disclosed herein, in certain embodiments, is a method for treatingan otic disorder comprising administering a composition disclosed hereinat least once every 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, or 15 days;at least once a week, once every two weeks, once every three weeks, onceevery four weeks, once every five weeks, or once every six weeks; or atleast once a month, once every two months, once every three months, onceevery four months, once every five months, once every six months, onceevery seven months, once every eight months, once every nine months,once every ten months, once every eleven months, or once every twelvemonths. In particular embodiments, the controlled-release compositionsdescribed herein provide a sustained dose of an otic structuremodulating agent or innate immune system modulating agent to the innerear between subsequent doses of the controlled-release composition. Thatis, taking one example only, if new doses of the otic structuremodulating agent or innate immune system modulating agentcontrolled-release composition are administered via intratympanicinjection to the round window membrane every 10 days, then thecontrolled-release composition provides an effective dose of an oticstructure modulating agent or innate immune system modulating agent tothe inner ear (e.g., across the round window membrane) during that10-day period.

In one aspect, the composition is administered so that the compositionis in contact with the crista fenestrae cochleae, the round windowmembrane or the tympanic cavity. In one aspect the composition isadministered by intratympanic injection.

Provided herein are pharmaceutical compositions or devices for use inthe treatment of an otic disease or condition formulated to provide atherapeutically effective amount of an otic structure modulating agent,the pharmaceutical compositions or devices comprising substantially lowdegradation products of the otic structure modulating agent, thepharmaceutical compositions or devices further comprising two or morecharacteristics selected from:

-   -   (i) between about 0.1% to about 10% by weight of the otic        structure modulating agent, or pharmaceutically acceptable        prodrug or salt thereof;    -   (ii) between about 14% to about 21% by weight of a        polyoxyethylene-polyoxypropylene triblock copolymer of general        formula E106 P70 E106;    -   (iii) sterile water, q.s., buffered to provide a pH between        about 5.5 and about 8.0;    -   (iv) multiparticulate otic structure modulating agent;    -   (v) a gelation temperature between about 19° C. to about 42° C.;    -   (vi) less than about 50 colony forming units (cfu) of        microbiological agents per gram of composition;    -   (vii) less than about 5 endotoxin units (EU) per kg of body        weight of a subject;    -   (viii) a mean dissolution time of about 30 hours for the otic        structure modulating agent; and    -   (ix) an apparent viscosity of about 100,000 cP to about 500,000        cP.

In some embodiments, the pharmaceutical composition comprises at leastthree of the aforementioned characteristics. In some embodiments, thepharmaceutical composition comprises at least four of the aforementionedcharacteristics. In some embodiments, the pharmaceutical compositioncomprises at least five of the aforementioned characteristics. In someembodiments, the pharmaceutical composition comprises at least six ofthe aforementioned characteristics. In some embodiments, thepharmaceutical composition comprises at least seven of theaforementioned characteristics. In some embodiments, the pharmaceuticalcomposition comprises all of the aforementioned characteristics.

In some embodiments, a pharmaceutical composition or device describedherein comprises:

-   -   (i) between about 0.1% to about 10% by weight of the otic        structure modulating agent, or pharmaceutically acceptable        prodrug or salt thereof;    -   (ii) between about 14% to about 21% by weight of a        polyoxyethylene-polyoxypropylene triblock copolymer of general        formula E106 P70 E106; and    -   (iii) multiparticulate otic structure modulating agent.

In some embodiments, a pharmaceutical composition or device describedherein comprises:

-   -   (i) between about 0.1% to about 10% by weight of the otic        structure modulating agent, or pharmaceutically acceptable        prodrug or salt thereof;    -   (ii) between about 14% to about 21% by weight of a        polyoxyethylene-polyoxypropylene triblock copolymer of general        formula E106 P70 E106;    -   (iii) multiparticulate otic structure modulating agent; and    -   (iv) a gelation temperature between about 19° C. to about 42° C.        Provided herein are pharmaceutical compositions or devices for        use in the treatment of an otic disease or condition formulated        to provide a therapeutically effective amount of a molecular        component of an otic structure, the pharmaceutical compositions        or devices comprising substantially low degradation products of        the otic structure enhancing agent, the pharmaceutical        compositions or devices further comprising two or more        characteristics selected from:    -   (i) between about 0.1% to about 10% by weight of the otic        structure enhancing agent, or pharmaceutically acceptable        prodrug or salt thereof;    -   (ii) between about 14% to about 21% by weight of a        polyoxyethylene-polyoxypropylene triblock copolymer of general        formula E106 P70 E106;    -   (iii) sterile water, q.s., buffered to provide a pH between        about 5.5 and about 8.0;    -   (iv) multiparticulate molecular component of an otic structure;    -   (v) a gelation temperature between about 19° C. to about 42° C.;    -   (vi) less than about 50 colony forming units (cfu) of        microbiological agents per gram of composition;    -   (vii) less than about 5 endotoxin units (EU) per kg of body        weight of a subject;    -   (viii) a mean dissolution time of about 30 hours for the otic        structure enhancing agent; and    -   (ix) an apparent viscosity of about 100,000 cP to about 500,000        cP.

In some embodiments, the pharmaceutical composition comprises at leastthree of the aforementioned characteristics. In some embodiments, thepharmaceutical composition comprises at least four of the aforementionedcharacteristics. In some embodiments, the pharmaceutical compositioncomprises at least five of the aforementioned characteristics. In someembodiments, the pharmaceutical composition comprises at least six ofthe aforementioned characteristics. In some embodiments, thepharmaceutical composition comprises at least seven of theaforementioned characteristics. In some embodiments, the pharmaceuticalcomposition comprises all of the aforementioned characteristics.

In some embodiments, a pharmaceutical composition or device describedherein comprises:

-   -   (i) between about 0.1% to about 10% by weight of the otic        structure enhancing agent, or pharmaceutically acceptable        prodrug or salt thereof;    -   (ii) between about 14% to about 21% by weight of a        polyoxyethylene-polyoxypropylene triblock copolymer of general        formula E106 P70 E106; and    -   (iii) multiparticulate molecular component of an otic structure.

In some embodiments, a pharmaceutical composition or device describedherein comprises:

-   -   (i) between about 0.1% to about 10% by weight of the otic        structure enhancing agent, or pharmaceutically acceptable        prodrug or salt thereof;    -   (ii) between about 14% to about 21% by weight of a        polyoxyethylene-polyoxypropylene triblock copolymer of general        formula E106 P70 E106;    -   (iii) multiparticulate molecular component of an otic structure;        and    -   (iv) a gelation temperature between about 19° C. to about 42° C.        Provided herein are pharmaceutical compositions or devices for        use in the treatment of an otic disease or condition formulated        to provide a therapeutically effective amount of an otic        structure degrading agent, the pharmaceutical compositions or        devices comprising substantially low degradation products of the        otic structure degrading agent, the pharmaceutical compositions        or devices further comprising two or more characteristics        selected from:    -   (i) between about 0.1% to about 10% by weight of the otic        structure degrading agent, or pharmaceutically acceptable        prodrug or salt thereof;    -   (ii) between about 14% to about 21% by weight of a        polyoxyethylene-polyoxypropylene triblock copolymer of general        formula E106 P70 E106;    -   (iii) sterile water, q.s., buffered to provide a pH between        about 5.5 and about 8.0;    -   (iv) multiparticulate otic structure degrading agent;    -   (v) a gelation temperature between about 19° C. to about 42° C.;    -   (vi) less than about 50 colony forming units (cfu) of        microbiological agents per gram of composition;    -   (vii) less than about 5 endotoxin units (EU) per kg of body        weight of a subject;    -   (viii) a mean dissolution time of about 30 hours for the otic        structure degrading agent; and    -   (ix) an apparent viscosity of about 100,000 cP to about 500,000        cP.

In some embodiments, the pharmaceutical composition comprises at leastthree of the aforementioned characteristics. In some embodiments, thepharmaceutical composition comprises at least four of the aforementionedcharacteristics. In some embodiments, the pharmaceutical compositioncomprises at least five of the aforementioned characteristics. In someembodiments, the pharmaceutical composition comprises at least six ofthe aforementioned characteristics. In some embodiments, thepharmaceutical composition comprises at least seven of theaforementioned characteristics. In some embodiments, the pharmaceuticalcomposition comprises all of the aforementioned characteristics.

In some embodiments, a pharmaceutical composition or device describedherein comprises:

-   -   (i) between about 0.1% to about 10% by weight of the otic        structure degrading agent, or pharmaceutically acceptable        prodrug or salt thereof;    -   (ii) between about 14% to about 21% by weight of a        polyoxyethylene-polyoxypropylene triblock copolymer of general        formula E106 P70 E106; and    -   (iii) multiparticulate otic structure degrading agent.

In some embodiments, a pharmaceutical composition or device describedherein comprises:

-   -   (i) between about 0.1% to about 10% by weight of the otic        structure degrading agent, or pharmaceutically acceptable        prodrug or salt thereof;    -   (ii) between about 14% to about 21% by weight of a        polyoxyethylene-polyoxypropylene triblock copolymer of general        formula E106 P70 E106;    -   (iii) multiparticulate otic structure degrading agent; and    -   (iv) a gelation temperature between about 19° C. to about 42° C.

Provided herein are pharmaceutical compositions or devices for use inthe treatment of an otic disease or condition formulated to provide atherapeutically effective amount of an innate immune system modulatingagent, the pharmaceutical compositions or devices comprisingsubstantially low degradation products of the innate immune systemmodulating agent, the pharmaceutical compositions or devices furthercomprising two or more characteristics selected from:

-   -   (i) between about 0.1% to about 10% by weight of the innate        immune system modulating agent, or pharmaceutically acceptable        prodrug or salt thereof;    -   (ii) between about 14% to about 21% by weight of a        polyoxyethylene-polyoxypropylene triblock copolymer of general        formula E106 P70 E106;    -   (iii) sterile water, q.s., buffered to provide a pH between        about 5.5 and about 8.0;    -   (iv) multiparticulate innate immune system modulating agent;    -   (v) a gelation temperature between about 19° C. to about 42° C.;    -   (vi) less than about 50 colony forming units (cfu) of        microbiological agents per gram of composition;    -   (vii) less than about 5 endotoxin units (EU) per kg of body        weight of a subject;    -   (viii) a mean dissolution time of about 30 hours for the innate        immune system modulating agent; and    -   (ix) an apparent viscosity of about 100,000 cP to about 500,000        cP.

In some embodiments, the pharmaceutical composition comprises at leastthree of the aforementioned characteristics. In some embodiments, thepharmaceutical composition comprises at least four of the aforementionedcharacteristics. In some embodiments, the pharmaceutical compositioncomprises at least five of the aforementioned characteristics. In someembodiments, the pharmaceutical composition comprises at least six ofthe aforementioned characteristics. In some embodiments, thepharmaceutical composition comprises at least seven of theaforementioned characteristics. In some embodiments, the pharmaceuticalcomposition comprises all of the aforementioned characteristics.

In some embodiments, a pharmaceutical composition or device describedherein comprises:

-   -   (i) between about 0.1% to about 10% by weight of the innate        immune system modulating agent, or pharmaceutically acceptable        prodrug or salt thereof;    -   (ii) between about 14% to about 21% by weight of a        polyoxyethylene-polyoxypropylene triblock copolymer of general        formula E106 P70 E106; and    -   (iii) multiparticulate innate immune system modulating agent.

In some embodiments, a pharmaceutical composition or device describedherein comprises:

-   -   (i) between about 0.1% to about 10% by weight of the innate        immune system modulating agent, or pharmaceutically acceptable        prodrug or salt thereof;    -   (ii) between about 14% to about 21% by weight of a        polyoxyethylene-polyoxypropylene triblock copolymer of general        formula E106 P70 E106;    -   (iii) multiparticulate innate immune system modulating agent;        and    -   (iv) a gelation temperature between about 19° C. to about 42° C.

Provided herein are methods of treating an otic disease or conditioncharacterized by excess otic structures comprising administering to anindividual in need thereof an intratympanic composition or devicecomprising: a therapeutically effective amount of an otic structuredegrading agent having substantially low degradation products; andwherein the composition or device comprises two or more characteristicsselected from:

-   -   (i) between about 0.1% to about 10% by weight of the otic        structure degrading agent, or pharmaceutically acceptable        prodrug or salt thereof;    -   (ii) between about 14% to about 21% by weight of a        polyoxyethylene-polyoxypropylene triblock copolymer of general        formula E106 P70 E106;    -   (iii) sterile water, q.s., buffered to provide a pH between        about 5.5 and about 8.0;    -   (iv) multiparticulate otic structure degrading agent;    -   (v) a gelation temperature between about 19° C. to about 42° C.;    -   (vi) less than about 50 colony forming units (cfu) of        microbiological agents per gram of composition, and    -   (vii) less than about 5 endotoxin units (EU) per kg of body        weight of a subject;    -   (viii) a mean dissolution time of about 30 hours for the otic        structure degrading agent; and    -   (ix) an apparent viscosity of about 100,000 cP to about 500,000        cP.

In some embodiments, the pharmaceutical composition comprises at leastthree of the aforementioned characteristics. In some embodiments, thepharmaceutical composition comprises at least four of the aforementionedcharacteristics. In some embodiments, the pharmaceutical compositioncomprises at least five of the aforementioned characteristics. In someembodiments, the pharmaceutical composition comprises at least six ofthe aforementioned characteristics. In some embodiments, thepharmaceutical composition comprises at least seven of theaforementioned characteristics. In some embodiments, the pharmaceuticalcomposition comprises all of the aforementioned characteristics.

In some embodiments, the otic structure degrading agent is released fromthe composition for a period of at least 3 days. In some embodiments,the otic structure degrading agent is essentially in the form ofmicronized particles. In some embodiments, the otic structure degradingagent degrades bone. In some embodiments, the otic structure degradingagent degrades a neuron. In some embodiments, the otic structuredegrading agent degrades a membrane. In some embodiments, the oticstructure degrading agent degrades liquor puris. In some embodiments,the otic structure degrading agent degrades endolymph or perilymph.

In some embodiments, a pharmaceutical composition or device describedabove provides a practical osmolarity between about 150 and 500 mOsm/L.In some embodiments, a pharmaceutical composition or device describedabove provides a practical osmolarity between about 200 and 400 mOsm/L.In some embodiments, a pharmaceutical composition or device describedabove provides a practical osmolarity between about 250 and 320 mOsm/L.

In some embodiments, the otic structure modulating agent or innateimmune system modulating agent is released from the pharmaceuticalcomposition or device described above for a period of at least 3 days.In some embodiments, the otic structure modulating agent or innateimmune system modulating agent is released from the pharmaceuticalcomposition or device described above for a period of at least 5 days.In some embodiments, the otic structure modulating agent or innateimmune system modulating agent is released from the pharmaceuticalcomposition or device described above for a period of at least 10 days.In some embodiments, the otic structure modulating agent or innateimmune system modulating agent is released from the pharmaceuticalcomposition or device described above for a period of at least 14 days.In some embodiments, the otic structure modulating agent or innateimmune system modulating agent is released from the pharmaceuticalcomposition or device described above for a period of at least onemonth.

In some embodiments, a pharmaceutical composition or device describedabove comprises an otic structure modulating agent or innate immunesystem modulating agent as a neutral molecule, a free acid, a free base,a salt or a prodrug. In some embodiments, a pharmaceutical compositionor device described above comprises an otic structure modulating agentor innate immune system modulating agent as a neutral molecule, a freeacid, a free base, a salt or a prodrug, or a combination thereof.

In some embodiments, a pharmaceutical composition or device describedabove comprises an otic structure modulating agent or innate immunesystem modulating agent as multiparticulates. In some embodiments, apharmaceutical composition or device described above comprises an oticstructure modulating agent or innate immune system modulating agent inthe form of micronized particles. In some embodiments, a pharmaceuticalcomposition or device described above comprises an otic structuremodulating agent or innate immune system modulating agent as micronizedpowders.

In some embodiments, a pharmaceutical composition or device describedabove comprises about 10% of a polyoxyethylene-polyoxypropylene triblockcopolymer of general formula E106 P70 E106 by weight of the composition.In some embodiments, a pharmaceutical composition or device describedabove comprises about 15% of a polyoxyethylene-polyoxypropylene triblockcopolymer of general formula E106 P70 E106 by weight of the composition.In some embodiments, a pharmaceutical composition or device describedabove comprises about 20% of a polyoxyethylene-polyoxypropylene triblockcopolymer of general formula E106 P70 E106 by weight of the composition.In some embodiments, a pharmaceutical composition or device describedabove comprises about 25% of a polyoxyethylene-polyoxypropylene triblockcopolymer of general formula E106 P70 E106 by weight of the composition.

In some embodiments, a pharmaceutical composition or device describedherein comprises about 1% of an otic structure modulating agent orinnate immune system modulating agent, or pharmaceutically acceptableprodrug or salt thereof, by weight of the composition. In someembodiments, a pharmaceutical composition or device described abovecomprises about 2% of an otic structure modulating agent or innateimmune system modulating agent, or pharmaceutically acceptable prodrugor salt thereof, by weight of the composition. In some embodiments, apharmaceutical composition or device described herein comprises about 3%of an otic structure modulating agent or innate immune system modulatingagent, or pharmaceutically acceptable prodrug or salt thereof, by weightof the composition. In some embodiments, a pharmaceutical composition ordevice described herein comprises about 4% of an otic structuremodulating agent or innate immune system modulating agent, orpharmaceutically acceptable prodrug or salt thereof, by weight of thecomposition. In some embodiments, a pharmaceutical composition or devicedescribed above comprises about 5% of an otic structure modulating agentor innate immune system modulating agent, or pharmaceutically acceptableprodrug or salt thereof, by weight of the composition. In someembodiments, a pharmaceutical composition or device described abovecomprises about 10% of an otic structure modulating agent or innateimmune system modulating agent, or pharmaceutically acceptable prodrugor salt thereof, by weight of the composition. In some embodiments, apharmaceutical composition or device described above comprises about 15%of an otic structure modulating agent or innate immune system modulatingagent, or pharmaceutically acceptable prodrug or salt thereof, by weightof the composition. In some embodiments, a pharmaceutical composition ordevice described above comprises about 20% of an otic structuremodulating agent or innate immune system modulating agent, orpharmaceutically acceptable prodrug or salt thereof, by weight of thecomposition. In some embodiments, a pharmaceutical composition or devicedescribed above comprises about 25% of an otic structure modulatingagent or innate immune system modulating agent, or pharmaceuticallyacceptable prodrug or salt thereof, by weight of the composition. Insome embodiments, a pharmaceutical composition or device described abovecomprises about 30% of an otic structure modulating agent or innateimmune system modulating agent, or pharmaceutically acceptable prodrugor salt thereof, by weight of the composition. In some embodiments, apharmaceutical composition or device described above comprises about 40%of an otic structure modulating agent or innate immune system modulatingagent, or pharmaceutically acceptable prodrug or salt thereof, by weightof the composition. In some embodiments, a pharmaceutical composition ordevice described above comprises about 50% of an otic structuremodulating agent or innate immune system modulating agent, orpharmaceutically acceptable prodrug or salt thereof, by weight of thecomposition. In some embodiments, a pharmaceutical composition or devicedescribed above comprises about 60% of an otic structure modulatingagent or innate immune system modulating agent, or pharmaceuticallyacceptable prodrug or salt thereof, by weight of the composition. Insome embodiments, a pharmaceutical composition or device described abovecomprises about 70% of an otic structure modulating agent or innateimmune system modulating agent, or pharmaceutically acceptable prodrugor salt thereof, by weight of the composition. In some embodiments, apharmaceutical composition or device described above comprises about 80%of an otic structure modulating agent or innate immune system modulatingagent, or pharmaceutically acceptable prodrug or salt thereof, by weightof the composition. In some embodiments, a pharmaceutical composition ordevice described above comprises about 90% of an otic structuremodulating agent or innate immune system modulating agent, orpharmaceutically acceptable prodrug or salt thereof, by weight of thecomposition.

In some embodiments, a pharmaceutical composition or device describedabove has a pH between about 5.5 and about 8.0. In some embodiments, apharmaceutical composition or device described above has a pH betweenabout 6.0 and about 8.0. In some embodiments, a pharmaceuticalcomposition or device described above has a pH between about 6.0 andabout 7.6.

In some embodiments, a pharmaceutical composition or device describedabove contains less than 100 colony forming units (cfu) ofmicrobiological agents per gram of composition. In some embodiments, apharmaceutical composition or device described above contains less than50 colony forming units (cfu) of microbiological agents per gram ofcomposition. In some embodiments, a pharmaceutical composition or devicedescribed above contains less than 10 colony forming units (cfu) ofmicrobiological agents per gram of composition.

In some embodiments, a pharmaceutical composition or device describedabove contains less than 5 endotoxin units (EU) per kg of body weight ofa subject. In some embodiments, a pharmaceutical composition or devicedescribed above contains less than 4 endotoxin units (EU) per kg of bodyweight of a subject.

In some embodiments, a pharmaceutical composition or device describedabove provides a gelation temperature between about between about 19° C.to about 42° C. In some embodiments, a pharmaceutical composition ordevice described above provides a gelation temperature between aboutbetween about 19° C. to about 37° C. In some embodiments, apharmaceutical composition or device described above provides a gelationtemperature between about between about 19° C. to about 30° C.

In some embodiments, the pharmaceutical composition or device is anauris-acceptable thermoreversible gel. In some embodiments, thepolyoxyethylene-polyoxypropylene triblock copolymer is biodegradableand/or bioeliminated (e.g., the copolymer is eliminated from the body bya biodegradation process, e.g., elimination in the urine, the feces orthe like). In some embodiments, a pharmaceutical composition or devicedescribed herein further comprises a mucoadhesive. In some embodiments,a pharmaceutical composition or device described herein furthercomprises a penetration enhancer. In some embodiments, a pharmaceuticalcomposition or device described herein further comprises a thickeningagent. In some embodiments, a pharmaceutical composition or devicedescribed herein further comprises a dye.

In some embodiments, a pharmaceutical composition or device describedherein further comprises a drug delivery device selected from a needleand syringe, a pump, a microinjection device, a wick, an in situ formingspongy material or combinations thereof.

In some embodiments, a pharmaceutical composition or device describedherein is a pharmaceutical composition or device wherein the oticstructure modulating agent or innate immune system modulating agent, orpharmaceutically acceptable salt thereof, has limited or no systemicrelease, systemic toxicity, poor PK characteristics, or combinationsthereof. In some embodiments, of the pharmaceutical compositions ordevices described herein, the otic structure modulating agent or innateimmune system modulating agent is in the form of a neutral molecule, afree base, a free acid, a salt, a prodrug, or a combination thereof. Insome embodiments, of the pharmaceutical compositions or devicesdescribed herein, the otic structure modulating agent or innate immunesystem modulating agent is administered in the form of a phosphate orester prodrug. In some embodiments, pharmaceutical compositions ordevices described herein comprise an otic structure modulating agent orinnate immune system modulating agent, or pharmaceutically acceptablesalt thereof, prodrug or combination thereof as an immediate releaseagent.

In some embodiments, pharmaceutical compositions or devices describedherein further comprise an additional therapeutic agent. In someembodiments, the additional therapeutic agent is a an acidifying agent,an anesthetic, an analgesic, an antibiotic, antiemetic, an antifungal,an anti-microbial agent, an antipsychotic (especially those in thephenothiazine class), an antiseptic, an antiviral, an astringent, achemotherapeutic agent, a collagen, a corticosteroid, a diuretic, akeratolytic agent, a nitric oxide synthase inhibitor, combinationsthereof.

In some embodiments, pharmaceutical compositions or devices describedherein are pharmaceutical compositions or devices wherein the pH of thepharmaceutical composition or device is between about 6.0 to about 7.6.

In some embodiments, of the pharmaceutical compositions or devicesdescribed herein, the ratio of a polyoxyethylene-polyoxypropylenetriblock copolymer of general formula E106 P70 E106 to a thickeningagent is from about 40:1 to about 5:1. In some embodiments, thethickening agent is carboxymethyl cellulose, hydroxypropyl cellulose orhydroxypropyl methylcellulose.

In some embodiments, the otic disease or condition is endolymphatichydrops, kinetosis, labyrinthitis, mal de debarquement, Meniere'sdisease, Meniere's syndrome, Ramsay Hunt's syndrome (Herpes zosterinfection), recurrent vestibulopathy, tinnitus, vertigo, microvascularcompression syndrome, utricular dysfunction, vestibular neuronitis,benign paroxysmal positional vertigo, or combinations thereof.

Also provided herein is a method of treating an otic disease orcondition comprising administering to an individual in need thereof anintratympanic composition or device comprising a therapeuticallyeffective amount of an otic structure modulating agent, the compositionor device comprising substantially low degradation products of an oticstructure modulating agent, the composition or device further comprisingtwo or more characteristics selected from:

-   -   (i) between about 0.1% to about 10% by weight of the otic        structure modulating agent, or pharmaceutically acceptable        prodrug or salt thereof;    -   (ii) between about 14% to about 21% by weight of a        polyoxyethylene-polyoxypropylene triblock copolymer of general        formula E106 P70 E106;    -   (iii) sterile water, q.s., buffered to provide a pH between        about 5.5 and about 8.0;    -   (iv) multiparticulate otic structure modulating agent;    -   (v) a gelation temperature between about 19° C. to about 42° C.;    -   (vi) less than about 50 colony forming units (cfu) of        microbiological agents per gram of composition, and    -   (vii) less than about 5 endotoxin units (EU) per kg of body        weight of a subject. Also provided herein is a method of        treating an otic disease or condition comprising administering        to an individual in need thereof an intratympanic composition or        device comprising a therapeutically effective amount of an otic        structure degrading agent, the composition or device comprising        substantially low degradation products of an otic structure        degrading agent, the composition or device further comprising        two or more characteristics selected from:    -   (i) between about 0.1% to about 10% by weight of the otic        structure degrading agent, or pharmaceutically acceptable        prodrug or salt thereof;    -   (ii) between about 14% to about 21% by weight of a        polyoxyethylene-polyoxypropylene triblock copolymer of general        formula E106 P70 E106;    -   (iii) sterile water, q.s., buffered to provide a pH between        about 5.5 and about 8.0;    -   (iv) multiparticulate otic structure degrading agent;    -   (v) a gelation temperature between about 19° C. to about 42° C.;    -   (vi) less than about 50 colony forming units (cfu) of        microbiological agents per gram of composition, and    -   (vii) less than about 5 endotoxin units (EU) per kg of body        weight of a subject.

Also provided herein is a method of treating an otic disease orcondition comprising administering to an individual in need thereof anintratympanic composition or device comprising a therapeuticallyeffective amount of otic structure enhancing agent, the composition ordevice comprising substantially low degradation products of oticstructure enhancing agent, the composition or device further comprisingtwo or more characteristics selected from:

-   -   (i) between about 0.1% to about 10% by weight of the otic        structure enhancing agent, or pharmaceutically acceptable        prodrug or salt thereof;    -   (ii) between about 14% to about 21% by weight of a        polyoxyethylene-polyoxypropylene triblock copolymer of general        formula E106 P70 E106;    -   (iii) sterile water, q.s., buffered to provide a pH between        about 5.5 and about 8.0;    -   (iv) multiparticulate molecular component of an otic structure;    -   (v) a gelation temperature between about 19° C. to about 42° C.;    -   (vi) less than about 50 colony forming units (cfu) of        microbiological agents per gram of composition, and    -   (vii) less than about 5 endotoxin units (EU) per kg of body        weight of a subject.

Also provided herein is a method of treating an otic disease orcondition comprising administering to an individual in need thereof anintratympanic composition or device comprising a therapeuticallyeffective amount of an innate immune system modulating agent, thecomposition or device comprising substantially low degradation productsof an innate immune system modulating agent, the composition or devicefurther comprising two or more characteristics selected from:

-   -   (i) between about 0.1% to about 10% by weight of the innate        immune system modulating agent, or pharmaceutically acceptable        prodrug or salt thereof;    -   (ii) between about 14% to about 21% by weight of a        polyoxyethylene-polyoxypropylene triblock copolymer of general        formula E106 P70 E106;    -   (iii) sterile water, q.s., buffered to provide a pH between        about 5.5 and about 8.0;    -   (iv) multiparticulate innate immune system modulating agent;    -   (v) a gelation temperature between about 19° C. to about 42° C.;    -   (vi) less than about 50 colony forming units (cfu) of        microbiological agents per gram of composition, and    -   (vii) less than about 5 endotoxin units (EU) per kg of body        weight of a subject.

In some embodiments of the methods described herein, the otic structuremodulating agent or innate immune system modulating agent is releasedfrom the composition or devices for a period of at least 3 days. In someembodiments of the methods described herein, the otic structuremodulating agent or innate immune system modulating agent is releasedfrom the composition or device for a period of at least 4 days. In someembodiments of the methods described herein, the otic structuremodulating agent or innate immune system modulating agent is releasedfrom the composition or device for a period of at least 5 days. In someembodiments of the methods described herein, the otic structuremodulating agent or innate immune system modulating agent is releasedfrom the composition or device for a period of at least 6 days. In someembodiments of the methods described herein, the otic structuremodulating agent or innate immune system modulating agent is releasedfrom the composition or device for a period of at least 7 days. In someembodiments of the methods described herein, the otic structuremodulating agent or innate immune system modulating agent is releasedfrom the composition or device for a period of at least 8 days. In someembodiments of the methods described herein, the otic structuremodulating agent or innate immune system modulating agent is releasedfrom the composition or device for a period of at least 9 days. In someembodiments of the methods described herein, the otic structuremodulating agent or innate immune system modulating agent is releasedfrom the composition or device for a period of at least 10 days. In someembodiments of the method described above, the otic structure modulatingagent or innate immune system modulating agent is essentially in theform of micronized particles.

In some embodiments of the methods described herein, the composition isadministered across the round window. In some embodiments of the methodsdescribed herein, the otic disease or condition is otitis externa,otitis media, mastoiditis, sensorineural hearing loss, ototoxicity,endolymphatic hydrops, labyrinthitis, Meniere's disease, Meniere'ssyndrome, microvascular compression syndrome, vestibular neuronitis,acoustic trauma, presbycusis, cholesteatoma, otosclerosis, Scheibesyndrome, Mondini-Michelle syndrome, Waardenburg's syndrome, Michelsyndrome, Alexander's ear deformity, hypertelorism, Jervell-LangeNielson syndrome, Refsum's syndrome, Usher's syndrome, or combinationsthereof.

BRIEF DESCRIPTION OF FIGURES

FIG. 1 illustrates a comparison of non-sustained release and sustainedrelease compositions.

FIG. 2 illustrates the effect of concentration on the viscosity ofaqueous solutions of Blanose refined CMC.

FIG. 3 illustrates the effect of concentration on the viscosity ofaqueous solutions of Methocel. FIG. 4 provides an illustrativerepresentation of the anatomy of the ear.

FIG. 5 illustrates tunable release of an active agent from fourcompositions.

DETAILED DESCRIPTION OF THE INVENTION

Provided herein are controlled-release otic structure modulatingcompositions and compositions to treat (e.g., ameliorate or reduce theeffects of) an otic disease, disorder, or condition characterized by anexcess or deficiency in an otic structure. In some embodiments, thecontrolled-release otic structure modulating compositions andcompositions treat (e.g., ameliorate or reduce the effects of) an oticdisease, disorder, or condition characterized by an excess of oticstructures. In some embodiments, the controlled-release otic structuremodulating compositions and compositions treat (e.g., ameliorate orreduce the effects of) an otic disease, disorder, or conditioncharacterized by a deficiency of otic structures. In some embodiments,the otic disease, disorder, or condition is otitis externa, otitismedia, mastoiditis, sensorineural hearing loss, ototoxicity,endolymphatic hydrops, labyrinthitis, Meniere's disease, Meniere'ssyndrome, microvascular compression syndrome, vestibular neuronitis,acoustic trauma, presbycusis, cholesteatoma, otosclerosis, Scheibesyndrome, Mondini-Michelle syndrome, Waardenburg's syndrome, Michelsyndrome, Alexander's ear deformity, hypertelorism, Jervell-LangeNielson syndrome, Refsum's syndrome, Usher's syndrome, or combinationsthereof.

Further provided herein are controlled-release complement modulatingcompositions and compositions to treat (e.g., ameliorate or reduce theeffects of) an otic disease, disorder, or condition characterized bydysfunction of the innate immune system. In some embodiments, thecontrolled-release complement modulating compositions and devices treat(e.g., ameliorate or reduce the effects of) an otic disease, disorder,or condition characterized by the over-activity of the innate immunesystem. In some embodiments, the otic disease, disorder, or condition isotitis externa, otitis media, mastoiditis, AIED, Ramsay Hunt's,reperfusion injury, labyrinthitis ossificans or combinations thereof.

In some embodiments, the otic structure modulating agent is an oticstructure degrading agent. In some embodiments, the otic structuremodulating agent is otic structure enhancing agent.

In some embodiments, the innate immune system modulating agent is acomplement cascade modulating agent and/or an anaphylatoxin modulator.In some embodiments, the innate immune system modulating agent is acomplement cascade antagonist and/or an anaphylatoxin antagonist. Insome embodiments, the innate immune system modulating agent is acomplement cascade agonist and/or an anaphylatoxin agonist.

A few therapeutic products are available for the treatment of oticdisorders; however, systemic routes via oral, intravenous orintramuscular routes are currently used to deliver these therapeuticagents. In some instances, systemic drug administration creates apotential inequality in drug concentration with higher circulatinglevels in the serum, and lower levels in the target auris media andauris interna organ structures. As a result, fairly large amounts ofdrug are required to overcome this inequality in order to deliversufficient, therapeutically effective quantities to the inner ear. Inaddition, systemic drug administration may increase the likelihood ofsystemic toxicities and adverse side effects as a result of the highserum amounts required to effectuate sufficient local delivery to thetarget site. Systemic toxicities may also occur as a result of liverbreakdown and processing of the therapeutic agents, forming toxicmetabolites that effectively erase any benefit attained from theadministered therapeutic.

To overcome the toxic and attendant side effects of systemic delivery,disclosed herein are methods and compositions and devices for localdelivery of therapeutic agents to targeted auris structures. Access to,for example, the vestibular and cochlear apparatus will occur throughthe auris media including round window membrane, the oval window/stapesfootplate, the annular ligament and through the otic capsule/temporalbone.

Intratympanic injection of therapeutic agents is the technique ofinjecting a therapeutic agent behind the tympanic membrane into theauris media and/or auris interna. This technique presents severalchallenges; for example, access to the round window membrane, the siteof drug absorption into the auris interna, is challenging.

Further, intra-tympanic injections create several unrecognized problemsnot addressed by currently available treatment regimens, such aschanging the osmolarity and pH of the perilymph and endolymph, andintroducing pathogens and endotoxins that directly or indirectly damageinner ear structures. One of the reasons the art may not have recognizedthese problems is that there are no approved intra-tympaniccompositions: the inner ear provides sui generis composition challenges.Thus, compositions developed for other parts of the body have little tono relevance for an intra-tympanic composition.

There is no guidance in the prior art regarding requirements (e.g.,level of sterility, pH, osmolarity) for otic compositions that aresuitable for administration to humans. There is wide anatomicaldisparity between the ears of animals across species. A consequence ofthe inter-species differences in auditory structures is that animalmodels of inner ear disease are often unreliable as a tool for testingtherapeutics that are being developed for clinical approval.

Provided herein are otic compositions that meet stringent criteria forpH, osmolarity, ionic balance, sterility, endotoxin and/or pyrogenlevels. The auris compositions described herein are compatible with themicroenvironment of the inner ear (e.g., the perilymph) and are suitablefor administration to humans. In some embodiments, the compositionsdescribed herein comprise dyes and aid visualization of the administeredcompositions obviating the need for invasive procedures (e.g., removalof perilymph) during preclinical and/or clinical development ofintratympanic therapeutics.

Provided herein are controlled-release otic structure modulatingcompositions and compositions to locally treat targeted aurisstructures, thereby avoiding side effects as a result of systemicadministration of the otic structure modulating compositions. Thelocally applied otic structure modulating compositions and devices arecompatible with the targeted auris structures, and administered eitherdirectly to the desired targeted auris structure (e.g., the cochlearregion, the tympanic cavity or the external ear), or administered to astructure in direct communication with areas of the auris interna (e.g.,the round window membrane, the crista fenestrae cochleae or the ovalwindow membrane). By specifically targeting an auris structure, adverseside effects as a result of systemic treatment are avoided. Moreover,clinical studies have shown the benefit of having long term exposure ofdrug to the perilymph of the cochlea, for example with improved clinicalefficacy of sudden hearing loss when the therapeutic agent is given onmultiple occasions. Thus, by providing a controlled-release oticstructure modulating composition to treat otic disorders, a constant,variable and/or extended source of an otic structure modulating agent orinnate immune system modulating agent is provided to the subjectsuffering from an otic disorder, reducing or eliminating uncertainty intreatment. Accordingly, one embodiment disclosed herein is to provide acomposition that enables an otic structure modulating agent or innateimmune system modulating agent to be released in therapeuticallyeffective doses either at variable or constant rates such as to ensure acontinuous release of an otic structure modulating agent or innateimmune system modulating agent. In some embodiments, an otic structuremodulating agent or innate immune system modulating agent disclosedherein is administered as an immediate release composition. In otherembodiments, an otic structure modulating agent or innate immune systemmodulating agent is administered as a sustained release composition,released either continuously, variably or in a pulsatile manner, orvariants thereof. In still other embodiments, an otic structuremodulating agent or innate immune system modulating agent composition isadministered as both an immediate release and sustained releasecomposition, released either continuously, variably or in a pulsatilemanner, or variants thereof. The release is optionally dependent onenvironmental or physiological conditions, for example, the externalionic environment (see, e.g. Oros® release system, Johnson & Johnson).

In addition, localized treatment of the targeted auris structure alsoaffords the use of previously undesired therapeutic agents, includingagents with poor pK profiles, poor uptake, low systemic release and/ortoxicity issues. Because of the localized targeting of the oticstructure modulating compositions and devices, as well as the biologicalblood barrier present in the auris interna, the risk of adverse effectswill be reduced as a result of treatment with previously characterizedtoxic or ineffective otic structure modulating agent or innate immunesystem modulating agents. Accordingly, also contemplated within thescope of the embodiments herein is the use of an otic structuremodulating agent or innate immune system modulating agents in thetreatment of disorders that have been previously rejected bypractitioners because of adverse effects or ineffectiveness of the oticstructure modulating agent or innate immune system modulating agent.

Also included within the embodiments disclosed herein is the use ofadditional auris-compatible agents in combination with the oticstructure modulating compositions and devices disclosed herein. Whenused, such agents assist in the treatment of hearing or equilibrium lossor dysfunction as a result of otitis externa, otitis media, mastoiditis,sensorineural hearing loss, ototoxicity, endolymphatic hydrops,labyrinthitis, Meniere's disease, Meniere's syndrome, microvascularcompression syndrome, vestibular neuronitis, acoustic trauma,presbycusis, cholesteatoma, otosclerosis, Scheibe syndrome,Mondini-Michelle syndrome, Waardenburg's syndrome, Michel syndrome,Alexander's ear deformity, hypertelorism, Jervell-Lange Nielsonsyndrome, Refsum's syndrome, Usher's syndrome, or combinations thereof.Accordingly, additional agents that ameliorate or reduce the effects ofotitis externa, otitis media, mastoiditis, sensorineural hearing loss,ototoxicity, endolymphatic hydrops, labyrinthitis, Meniere's disease,Meniere's syndrome, microvascular compression syndrome, vestibularneuronitis, acoustic trauma, presbycusis, cholesteatoma, otosclerosis,Scheibe syndrome, Mondini-Michelle syndrome, Waardenburg's syndrome,Michel syndrome, Alexander's ear deformity, hypertelorism, Jervell-LangeNielson syndrome, Refsum's syndrome, Usher's syndrome, otitis externa,otitis media, mastoiditis, AIED, Ramsay Hunt's, reperfusion injury,labyrinthitis ossificans, or combinations thereof are also contemplatedto be used in combination with an otic structure modulating agent orinnate immune system modulating agent. In some embodiments, theadditional agent is an acidifying agent, an anesthetic, an analgesic, anantibiotic, antiemetic, an antifungal, an anti-microbial agent, anantipsychotic (especially those in the phenothiazine class), anantiseptic, an antiviral, an astringent, a chemotherapeutic agent, acollagen, a corticosteroid, a diuretic, a keratolytic agent, a nitricoxide synthase inhibitor, or combinations thereof.

In some embodiments, an auris-acceptable controlled-release oticstructure modulating composition described herein is administered to thetarget ear region and an oral dose of an otic structure modulating agentor innate immune system modulating agent is additionally administered.In some embodiments, an oral dose of an otic structure modulating agentor innate immune system modulating agent is administered beforeadministration of the auris-acceptable controlled-release otic structuremodulating composition, and then the oral dose is tapered off over theperiod of time that the controlled-release otic structure modulatingcomposition is provided. Alternatively, an oral dose of an oticstructure modulating agent or innate immune system modulating agent isadministered during administration of the controlled-release oticstructure modulating composition, and then the oral dose is tapered offover the period of time that the controlled-release otic structuremodulating composition is provided. Alternatively, an oral dose of anotic structure modulating agent or innate immune system modulating agentis administered after administration of the controlled-release oticstructure modulating composition, and then the oral dose is tapered offover the period of time that the controlled-release otic structuremodulating composition is provided.

In addition, the otic structure modulating agent or innate immune systemmodulating agent pharmaceutical compositions or compositions or devicesincluded herein also include carriers, adjuvants (e.g., preserving,stabilizing, wetting or emulsifying agents), solution promoters, saltsfor regulating the osmotic pressure, and/or buffers. Such carriers,adjuvants, and other excipients will be compatible with the environmentin the targeted auris structure(s). Specifically contemplated arecarriers, adjuvants and excipients that lack ototoxicity or areminimally ototoxic in order to allow effective treatment of the oticdisorders contemplated herein with minimal side effects in the targetedregions or areas.

Intratympanic injection of delivery devices creates several additionalproblems that must also be addressed before the composition or devicecan be administered. For example, there are many excipients that areototoxic. While these excipients can be used when formulating an activeagent for delivery by another method (e.g., topical), their use shouldbe limited, reduced or eliminated when formulating a composition ordevice to be administered to the ear due to their ototoxic effects.

By way of non-limiting example, the use of the following commonly usedsolvents should be limited, reduced or eliminated when formulatingagents for administration to the ear: alcohols, propylene glycol, andcyclohexane. Thus, in some embodiments, a device disclosed herein isfree or substantially free of alcohols, propylene glycol, andcyclohexane. In some embodiments, a device disclosed herein comprisesless than about 50 ppm of each of alcohols, propylene glycol, andcyclohexane. In some embodiments, a device disclosed herein comprisesless than about 25 ppm of each of alcohols, propylene glycol, andcyclohexane. In some embodiments, a device disclosed herein comprisesless than about 20 ppm of each of alcohols, propylene glycol, andcyclohexane. In some embodiments, a device disclosed herein comprisesless than about 10 ppm of each of alcohols, propylene glycol, andcyclohexane. In some embodiments, a device disclosed herein comprisesless than about 5 ppm of each of alcohols, propylene glycol, andcyclohexane. In some embodiments, a device disclosed herein comprisesless than about 1 ppm of each of alcohols, propylene glycol, andcyclohexane.

Further, by way of non-limiting example, the use of the followingcommonly utilized preservatives should be limited, reduced or eliminatedwhen formulating agents for administration to the ear: Benzethoniumchloride, Benzalkonium chloride, and Thiomersal. Thus, in someembodiments, a device disclosed herein is free or substantially free ofbenzethonium chloride, benzalkonium chloride, and thiomersal. In someembodiments, a device disclosed herein comprises less than about 50 ppmof each of benzethonium chloride, benzalkonium chloride, and thiomersal.In some embodiments, a device disclosed herein comprises less than about25 ppm of each of benzethonium chloride, benzalkonium chloride, andthiomersal. In some embodiments, a device disclosed herein comprisesless than about 20 ppm of each of benzethonium chloride, benzalkoniumchloride, and thiomersal. In some embodiments, a device disclosed hereincomprises less than about 10 ppm of each of benzethonium chloride,benzalkonium chloride, and thiomersal. In some embodiments, a devicedisclosed herein comprises less than about 5 ppm of each of benzethoniumchloride, benzalkonium chloride, and thiomersal. In some embodiments, adevice disclosed herein comprises less than about 1 ppm of each ofbenzethonium chloride, benzalkonium chloride, and thiomersal.

Certain antiseptics used to disinfect components of therapeuticpreparations (or the devices utilized to administer the preparations)should be limited, reduced, or eliminated in otic preparations. Forexample, acetic acid, iodine, and merbromin are all known to beototoxic. Additionally, chlorhexidene, a commonly used antiseptic,should be limited, reduced or eliminated to disinfect any component ofan otic preparation (including devices used to administer thepreparation) as it is highly ototoxic in minute concentrations (e.g.,0.05%). Thus, in some embodiments, a device disclosed herein is free orsubstantially free of acetic acid, iodine, merbromin, and chlorhexidene.In some embodiments, a device disclosed herein comprises less than about50 ppm of each of acetic acid, iodine, merbromin, and chlorhexidene. Insome embodiments, a device disclosed herein comprises less than about 25ppm of each of acetic acid, iodine, merbromin, and chlorhexidene. Insome embodiments, a device disclosed herein comprises less than about 20ppm of each of acetic acid, iodine, merbromin, and chlorhexidene. Insome embodiments, a device disclosed herein comprises less than about 10ppm of each of acetic acid, iodine, merbromin, and chlorhexidene. Insome embodiments, a device disclosed herein comprises less than about 5ppm of each of acetic acid, iodine, merbromin, and chlorhexidene. Insome embodiments, a device disclosed herein comprises less than about 1ppm of each of acetic acid, iodine, merbromin, and chlorhexidene.

Further, otic preparations require particularly low concentrations ofseveral potentially-common contaminants that are known to be ototoxic.Other dosage forms, while seeking to limit the contaminationattributable to these compounds, do not require the stringentprecautions that otic preparations require. For example, the followingcontaminants should be absent or nearly absent from otic preparations:arsenic, lead, mercury, and tin. Thus, in some embodiments, a devicedisclosed herein is free or substantially free of arsenic, lead,mercury, and tin. In some embodiments, a device disclosed hereincomprises less than about 50 ppm of each of arsenic, lead, mercury, andtin. In some embodiments, a device disclosed herein comprises less thanabout 25 ppm of each of arsenic, lead, mercury, and tin. In someembodiments, a device disclosed herein comprises less than about 20 ppmof each of arsenic, lead, mercury, and tin. In some embodiments, adevice disclosed herein comprises less than about 10 ppm of each ofarsenic, lead, mercury, and tin. In some embodiments, a device disclosedherein comprises less than about 5 ppm of each of arsenic, lead,mercury, and tin. In some embodiments, a device disclosed hereincomprises less than about 1 ppm of each of arsenic, lead, mercury, andtin.

To prevent ototoxicity, otic structure modulating agent or innate immunesystem modulating agent pharmaceutical compositions or compositions ordevices disclosed herein are optionally targeted to distinct regions ofthe targeted auris structures, including but not limited to the tympaniccavity, vestibular bony and membranous labyrinths, cochlear bony andmembranous labyrinths and other anatomical or physiological structureslocated within the auris interna.

CERTAIN DEFINITIONS

The term “auris-acceptable” with respect to a composition, compositionor ingredient, as used herein, includes having no persistent detrimentaleffect on the auris media (or middle ear) and the auris interna (orinner ear) of the subject being treated. By “auris-pharmaceuticallyacceptable,” as used herein, refers to a material, such as a carrier ordiluent, which does not abrogate the biological activity or propertiesof the compound in reference to the auris media (or middle ear) and theauris interna (or inner ear), and is relatively or is reduced intoxicity to the auris media (or middle ear) and the auris interna (orinner ear), i.e., the material is administered to an individual withoutcausing undesirable biological effects or interacting in a deleteriousmanner with any of the components of the composition in that it iscontained.

As used herein, amelioration or lessening of the symptoms of aparticular otic disease, disorder or condition by administration of aparticular compound or pharmaceutical composition refers to any decreaseof severity, delay in onset, slowing of progression, or shortening ofduration, whether permanent or temporary, lasting or transient that isattributed to or associated with administration of the compound orcomposition.

“Antioxidants” are auris-pharmaceutically acceptable antioxidants, andinclude, for example, butylated hydroxytoluene (BHT), sodium ascorbate,ascorbic acid, sodium metabisulfite and tocopherol. In certainembodiments, antioxidants enhance chemical stability where required.Antioxidants are also used to counteract the ototoxic effects of certaintherapeutic agents, including agents that are used in combination withthe otic structure modulating agent or innate immune system modulatingagents disclosed herein.

“Auris interna” refers to the inner ear, including the cochlea and thevestibular labyrinth, and the round window that connects the cochleawith the middle ear.

“Auris-bioavailability” or “Auris-interna bioavailability” or“Auris-media bioavailability” or “Auris-externa bioavailability” refersto the percentage of the administered dose of compounds disclosed hereinthat becomes available in the targeted auris structure of the animal orhuman being studied.

“Auris media” refers to the middle ear, including the tympanic cavity,auditory ossicles and oval window, which connects the middle ear withthe inner ear.

“Auris externa” refers to the outer ear, including the pinna, theauditory canal, and the tympanic membrane, which connects the outer earwith the middle ear.

“Blood plasma concentration” refers to the concentration of compoundsprovided herein in the plasma component of blood of a subject.

“Carrier materials” are excipients that are compatible with oticstructure modulating agent or innate immune system modulating agent(s),the targeted auris structure(s) and the release profile properties ofthe auris-acceptable pharmaceutical compositions. Such carrier materialsinclude, e.g., binders, suspending agents, disintegration agents,filling agents, surfactants, solubilizers, stabilizers, lubricants,wetting agents, diluents, and the like. “Auris-pharmaceuticallycompatible carrier materials” include, but are not limited to, acacia,gelatin, colloidal silicon dioxide, calcium glycerophosphate, calciumlactate, maltodextrin, glycerine, magnesium silicate,polyvinylpyrrolidone (PVP), cholesterol, cholesterol esters, sodiumcaseinate, soy lecithin, taurocholic acid, phosphatidylcholine, sodiumchloride, tricalcium phosphate, dipotassium phosphate, cellulose andcellulose conjugates, sugars sodium stearoyl lactylate, carrageenan,monoglyceride, diglyceride, pregelatinized starch, and the like.

The term “complement modulating agent”, as used herein, means an agentthat increases or inhibits the activity of a component of the complementsystem. In some embodiments, the complement modulating agent increasesthe activity of a component of the complement system. In someembodiments, the complement modulating agent inhibits (partially orfully) the activity of a component of the complement system.

The term “diluent” refers to chemical compounds that are used to dilutethe otic structure modulating agent or innate immune system modulatingagent prior to delivery and that are compatible with the targeted aurisstructure(s).

“Dispersing agents,” and/or “viscosity modulating agents” are materialsthat control the diffusion and homogeneity of the otic structuremodulating agent or innate immune system modulating agent through liquidmedia. Examples of diffusion facilitators/dispersing agents include butare not limited to hydrophilic polymers, electrolytes, Tween® 60 or 80,PEG, polyvinylpyrrolidone (PVP; commercially known as Plasdone®, and thecarbohydrate-based dispersing agents such as, for example, hydroxypropylcelluloses (e.g., HPC, HPC-SL, and HPC-L), hydroxypropylmethylcelluloses (e.g., HPMC K100, HPMC K4M, HPMC K15M, and HPMC K100M),carboxymethylcellulose sodium, methylcellulose, hydroxyethylcellulose,hydroxypropylcellulose, hydroxypropylmethylcellulose phthalate,hydroxypropylmethylcellulose acetate stearate (HPMCAS), noncrystallinecellulose, magnesium aluminum silicate, triethanolamine, polyvinylalcohol (PVA), vinyl pyrrolidone/vinyl acetate copolymer (S630),4-(1,1,3,3-tetramethylbutyl)-phenol polymer with ethylene oxide andformaldehyde (also known as tyloxapol), poloxamers (e.g., Pluronic F127,Pluronics F68®, F88®, and F108®, which are block copolymers of ethyleneoxide and propylene oxide); and poloxamines (e.g., Tetronic 908®, alsoknown as Poloxamine 908®, which is a tetrafunctional block copolymerderived from sequential addition of propylene oxide and ethylene oxideto ethylenediamine (BASF Corporation, Parsippany, N.J.)),polyvinylpyrrolidone K12, polyvinylpyrrolidone K17, polyvinylpyrrolidoneK25, or polyvinylpyrrolidone K30, polyvinylpyrrolidone/vinyl acetatecopolymer (S-630), polyethylene glycol, e.g., the polyethylene glycolhas a molecular weight of about 300 to about 6000, or about 3350 toabout 4000, or about 7000 to about 5400, sodium carboxymethylcellulose,methylcellulose, polysorbate-80, sodium alginate, gums, such as, e.g.,gum tragacanth and gum acacia, guar gum, xanthans, including xanthangum, sugars, cellulosics, such as, e.g., sodium carboxymethylcellulose,methylcellulose, sodium carboxymethylcellulose, polysorbate-80, sodiumalginate, polyethoxylated sorbitan monolaurate, polyethoxylated sorbitanmonolaurate, povidone, carbomers, polyvinyl alcohol (PVA), alginates,chitosans and combinations thereof. Plasticizers such as cellulose ortriethyl cellulose are also be used as dispersing agents. Optionaldispersing agents useful in liposomal dispersions and self-emulsifyingdispersions of the otic structure modulating agent or innate immunesystem modulating agents disclosed herein are dimyristoyl phosphatidylcholine, phosphatidyl cholines (c8-c18), phosphatidylethanolamines(c8-c18), phosphatidyl glycerols (c8-c18), natural phosphatidyl cholinefrom eggs or soy, natural phosphatidyl glycerol from eggs or soy,cholesterol and isopropyl myristate.

“Drug absorption” or “absorption” refers to the process of movement ofthe otic structure modulating agent or innate immune system modulatingagent(s) from the localized site of administration, by way of exampleonly, the round window membrane of the inner ear, and across a barrier(the round window membranes, as described below) into the auris internaor inner ear structures. The terms “co-administration” or the like, asused herein, are meant to encompass administration of the otic structuremodulating agent or innate immune system modulating agents to a singlepatient, and are intended to include treatment regimens in that the oticstructure modulating agent or innate immune system modulating agents areadministered by the same or different route of administration or at thesame or different time.

The terms “effective amount” or “therapeutically effective amount,” asused herein, refer to a sufficient amount of the otic structuremodulating agent or innate immune system modulating agents beingadministered that would be expected to relieve to some extent one ormore of the symptoms of the disease or condition being treated. Forexample, the result of administration of the otic structure modulatingagent or innate immune system modulating agents disclosed herein isreduction and/or alleviation of the signs, symptoms, or causes ofMeniere's disease. For example, an “effective amount” for therapeuticuses is the amount of the otic structure modulating agent or innateimmune system modulating agent, including a composition as disclosedherein required to provide a decrease or amelioration in diseasesymptoms without undue adverse side effects. The term “therapeuticallyeffective amount” includes, for example, a prophylactically effectiveamount. An “effective amount” of an otic structure modulating agent orinnate immune system modulating agent composition disclosed herein is anamount effective to achieve a desired pharmacologic effect ortherapeutic improvement without undue adverse side effects. It isunderstood that “an effective amount” or “a therapeutically effectiveamount” varies, in some embodiments, from subject to subject, due tovariation in metabolism of the compound administered, age, weight,general condition of the subject, the condition being treated, theseverity of the condition being treated, and the judgment of theprescribing physician. It is also understood that “an effective amount”in an extended-release dosing format may differ from “an effectiveamount” in an immediate-release dosing format based upon pharmacokineticand pharmacodynamic considerations.

The terms “enhance” or “enhancing” refers to an increase or prolongationof either the potency or duration of a desired effect of the oticstructure modulating agent or innate immune system modulating agent, ora diminution of any adverse symptoms such as localized pain that isconsequent upon administration of the therapeutic agent. Thus, in regardto enhancing the effect of the otic structure modulating agent or innateimmune system modulating agents disclosed herein, the term “enhancing”refers to the ability to increase or prolong, either in potency orduration, the effect of other therapeutic agents that are used incombination with the otic structure modulating agent or innate immunesystem modulating agents disclosed herein. An “enhancing-effectiveamount,” as used herein, refers to an amount of an otic structuremodulating agent or innate immune system modulating agents, or othertherapeutic agent, which is adequate to enhance the effect of anothertherapeutic agent or otic structure modulating agent or innate immunesystem modulating agents in a desired system. When used in a patient,amounts effective for this use will depend on the severity and course ofthe disease, disorder or condition, previous therapy, the patient'shealth status and response to the drugs, and the judgment of thetreating physician.

The term “inhibiting” includes preventing, slowing, or reversing thedevelopment of a condition, for example, otitis externa, or advancementof a condition in a patient necessitating treatment.

The term “innate immune system modulating agent”, as used herein, meansan agent that increases or inhibits the activity of a component of theinnate immune system. In some embodiments, the innate immune systemmodulating agent increases the activity of a component of the innateimmune system. In some embodiments, the innate immune system modulatingagent inhibits (partially or fully) the activity of a component of theinnate immune system.

“Balance disorder” refers to a disorder, illness, or condition whichcauses a subject to feel unsteady, or to have a sensation of movement.Included in this definition are dizziness, vertigo, disequilibrium, andpre-syncope. Diseases which are classified as balance disorders include,but are not limited to, mal de debarquement, benign paroxysmalpositional vertigo, and labyrinthitis.

The terms “kit” and “article of manufacture” are used as synonyms.

As used herein, the term “otic intervention” means an external insult ortrauma to one or more auris structures and includes implants, oticsurgery, injections, cannulations, or the like. Implants includeauris-interna or auris-media medical devices, examples of which includecochlear implants, hearing sparing devices, hearing-improvement devices,short electrodes, micro-prostheses or piston-like prostheses; needles;stem cell transplants; drug delivery devices; any cell-basedtherapeutic; or the like. Otic surgery includes middle ear surgery,inner ear surgery, typanostomy, cochleostomy, labyrinthotomy,mastoidectomy, stapedectomy, stapedotomy, tympanostomy, endolymphaticsacculotomy or the like. Injections include intratympanic injections,intracochlear injections, injections across the round window membrane orthe like. Cannulations include intratympanic, intracochlear,endolymphatic, perilymphatic or vestibular cannulations or the like.

“Otic structure modulating agent”, as used herein, means otic structureenhancing agent, or an agent that degrades the molecular components ofan otic structure.

“Pharmacokinetics” refers to the factors that determine the attainmentand maintenance of the appropriate concentration of drug at the desiredsite within the targeted auris structure.

In prophylactic applications, compositions containing the agentsdescribed herein are administered to a patient susceptible to orotherwise at risk of a particular disease, disorder or condition, forotitis externa, otitis media, mastoiditis, sensorineural hearing loss,ototoxicity, endolymphatic hydrops, labyrinthitis, Meniere's disease,Meniere's syndrome, microvascular compression syndrome, vestibularneuronitis, acoustic trauma, presbycusis, cholesteatoma, otosclerosis,Scheibe syndrome, Mondini-Michelle syndrome, Waardenburg's syndrome,Michel syndrome, Alexander's ear deformity, hypertelorism, Jervell-LangeNielson syndrome, Refsum's syndrome, and Usher's syndrome. Such anamount is defined to be a “prophylactically effective amount or dose.”In this use, the precise amounts also depend on the patient's state ofhealth, weight, and the like. As used herein, a “pharmaceutical device”includes any composition described herein that, upon administration toan ear, provides a reservoir for extended release of an active agentdescribed herein.

The mean residence time (MRT) is the average time that molecules of anactive agent reside in an otic structure after a dose.

A “prodrug” refers to the otic structure modulating agent or innateimmune system modulating agent that is converted into the parent drug invivo. In certain embodiments, a prodrug is enzymatically metabolized byone or more steps or processes to the biologically, pharmaceutically ortherapeutically active form of the compound. To produce a prodrug, apharmaceutically active compound is modified such that the activecompound will be regenerated upon in vivo administration. In oneembodiment, the prodrug is designed to alter the metabolic stability orthe transport characteristics of a drug, to mask side effects ortoxicity, or to alter other characteristics or properties of a drug.Compounds provided herein, in some embodiments, are derivatized intosuitable prodrugs.

“Round window membrane” is the membrane in humans that covers thefenestrae cochlea (also known as the circular window, fenestrae rotunda,or round window). In humans, the thickness of round window membrane isabout 70 micron.

“Solubilizers” refers to auris-acceptable compounds such as triacetin,triethylcitrate, ethyl oleate, ethyl caprylate, sodium lauryl sulfate,sodium caprate, sucrose esters, alkylglucosides, sodium doccusate,vitamin E TPGS, dimethylacetamide, N-methylpyrrolidone,N-hydroxyethylpyrrolidone, polyvinylpyrrolidone, hydroxypropylmethylcellulose, hydroxypropyl cyclodextrins, ethanol, n-butanol, isopropylalcohol, cholesterol, bile salts, polyethylene glycol 200-600,glycofurol, transcutol, propylene glycol, and dimethyl isosorbide andthe like.

“Stabilizers” refers to compounds such as any antioxidation agents,buffers, acids, preservatives and the like that are compatible with theenvironment of the targeted auris structure. Stabilizers include but arenot limited to agents that will do any of (1) improve the compatibilityof excipients with a container, or a delivery system, including asyringe or a glass bottle, (2) improve the stability of a component ofthe composition, or (3) improve composition stability.

As used herein, the term “substantially low degradation products” meansless than 5% by weight of the active agent are degradation products ofthe active agent. In further embodiments, the term means less than 3% byweight of the active agent are degradation products of the active agent.In yet further embodiments, the term means less than 2% by weight of theactive agent are degradation products of the active agent. In furtherembodiments, the term means less than 1% by weight of the active agentare degradation products of the active agent.

As used herein, “excess otic structures” include, by way of example,excess bone growth (e.g. in the stapes), blockage of otic structures(e.g., due to excessive secretion of mucous, pus or effusion), excesseffusion in the inner ear (e.g., due to inflammation) or any otherabnormality in any otic structure that can cause an otic disease orcondition described herein.

As used herein “essentially in the form of micronized powder” includes,by way of example only, greater than 70% by weight of the active agentis in the form of micronized particles of the active agent. In furtherembodiments, the term means greater than 80% by weight of the activeagent is in the form of micronized particles of the active agent. In yetfurther embodiments, the term means greater than 90% by weight of theactive agent is in the form of micronized particles of the active agent.

“Steady state,” as used herein, is when the amount of drug administeredto the targeted auris structure is equal to the amount of drugeliminated within one dosing interval resulting in a plateau or constantlevels of drug exposure within the targeted structure.

As used herein, the term “subject” is used to mean any animal,preferably a mammal, including a human or non-human. The terms patientand subject may be used interchangeably. Neither term is to beinterpreted as requiring the supervision of a medical professional(e.g., a doctor, nurse, physician's assistant, orderly, hospice worker).

“Surfactants” refers to compounds that are auris-acceptable, such assodium lauryl sulfate, sodium docusate, Tween® 60 or 80, triacetin,vitamin E TPGS, sorbitan monooleate, polyoxyethylene sorbitanmonooleate, polysorbates, polaxomers, bile salts, glyceryl monostearate,copolymers of ethylene oxide and propylene oxide, e.g., Pluronic®(BASF), and the like. Some other surfactants include polyoxyethylenefatty acid glycerides and vegetable oils, e.g., polyoxyethylene (60)hydrogenated castor oil; and polyoxyethylene alkylethers and alkylphenylethers, e.g., octoxynol 10, octoxynol 40. In some embodiments,surfactants are included to enhance physical stability or for otherpurposes.

The terms “treat,” “treating” or “treatment,” as used herein, includealleviating, abating or ameliorating a disease or condition symptoms,preventing additional symptoms, ameliorating or preventing theunderlying metabolic causes of symptoms, inhibiting the disease orcondition, e.g., arresting the development of the disease or condition,relieving the disease or condition, causing regression of the disease orcondition, relieving a condition caused by the disease or condition, orstopping the symptoms of the disease or condition eitherprophylactically and/or therapeutically.

Other objects, features, and advantages of the methods and compositionsdescribed herein will become apparent from the following detaileddescription. It should be understood, however, which the detaileddescription and the specific examples, while indicating specificembodiments, are given by way of illustration only.

Anatomy of the Ear

As shown in FIG. 4, the outer ear is the external portion of the organand is composed of the pinna (auricle), the auditory canal (externalauditory meatus) and the outward facing portion of the tympanicmembrane, also known as the ear drum. The pinna, which is the fleshypart of the external ear that is visible on the side of the head,collects sound waves and directs them toward the auditory canal. Thus,the function of the outer ear, in part, is to collect and direct soundwaves towards the tympanic membrane and the middle ear.

The middle ear is an air-filled cavity, called the tympanic cavity,behind the tympanic membrane. The tympanic membrane, also known as theear drum, is a thin membrane that separates the external ear from themiddle ear. The middle ear lies within the temporal bone, and includeswithin this space the three ear bones (auditory ossicles): the malleus,the incus and the stapes. The auditory ossicles are linked together viatiny ligaments, which form a bridge across the space of the tympaniccavity. The malleus, which is attached to the tympanic membrane at oneend, is linked to the incus at its anterior end, which in turn is linkedto the stapes. The stapes is attached to the oval window, one of twowindows located within the tympanic cavity. A fibrous tissue layer,known as the annular ligament connects the stapes to the oval window.Sound waves from the outer ear first cause the tympanic membrane tovibrate. The vibration is transmitted across to the cochlea through theauditory ossicles and oval window, which transfers the motion to thefluids in the auris interna. Thus, the auditory ossicles are arranged toprovide a mechanical linkage between the tympanic membrane and the ovalwindow of the fluid-filled auris interna, where sound is transformed andtransduced to the auris interna for further processing. Stiffness,rigidity or loss of movement of the auditory ossicles, tympanic membraneor oval window leads to hearing loss, e.g. otosclerosis, or rigidity ofthe stapes bone.

The tympanic cavity also connects to the throat via the eustachian tube.The eustachian tube provides the ability to equalize the pressurebetween the outside air and the middle ear cavity. The round window, acomponent of the auris interna but that is also accessible within thetympanic cavity, opens into the cochlea of the auris interna. The roundwindow is covered by round window membrane, which consists of threelayers: an external or mucous layer, an intermediate or fibrous layer,and an internal membrane, which communicates directly with the cochlearfluid. The round window, therefore, has direct communication with theauris interna via the internal membrane.

Movements in the oval and round window are interconnected, i.e. as thestapes bone transmits movement from the tympanic membrane to the ovalwindow to move inward against the auris interna fluid, the round window(round window membrane) is correspondingly pushed out and away from thecochlear fluid. This movement of the round window allows movement offluid within the cochlea, which leads in turn to movement of thecochlear inner hair cells, allowing hearing signals to be transduced.Stiffness and rigidity in round window membrane leads to hearing lossbecause of the lack of ability of movement in the cochlear fluid. Recentstudies have focused on implanting mechanical transducers onto the roundwindow, which bypasses the normal conductive pathway through the ovalwindow and provides amplified input into the cochlear chamber.

Auditory signal transduction takes place in the auris interna. Thefluid-filled auris interna, or inner ear, consists of two majorcomponents: the cochlear and the vestibular apparatus. The auris internais located in part within the osseous or bony labyrinth, an intricateseries of passages in the temporal bone of the skull. The vestibularapparatus is the organ of balance and consists of the threesemi-circular canals and the vestibule. The three semi-circular canalsare arranged relative to each other such that movement of the head alongthe three orthogonal planes in space can be detected by the movement ofthe fluid and subsequent signal processing by the sensory organs of thesemi-circular canals, called the crista ampullaris. The cristaampullaris contains hair cells and supporting cells, and is covered by adome-shaped gelatinous mass called the cupula. The hairs of the haircells are embedded in the cupula. The semi-circular canals detectdynamic equilibrium, the equilibrium of rotational or angular movements.

When the head turns rapidly, the semicircular canals move with the head,but endolymph fluid located in the membranous semi-circular canals tendsto remain stationary. The endolymph fluid pushes against the cupula,which tilts to one side. As the cupula tilts, it bends some of the hairson the hair cells of the crista ampullaris, which triggers a sensoryimpulse. Because each semicircular canal is located in a differentplane, the corresponding crista ampullaris of each semi-circular canalresponds differently to the same movement of the head. This creates amosaic of impulses that are transmitted to the central nervous system onthe vestibular branch of the vestibulocochlear nerve. The centralnervous system interprets this information and initiates the appropriateresponses to maintain balance. Of importance in the central nervoussystem is the cerebellum, which mediates the sense of balance andequilibrium.

The vestibule is the central portion of the auris interna and containsmechanoreceptors bearing hair cells that ascertain static equilibrium,or the position of the head relative to gravity. Static equilibriumplays a role when the head is motionless or moving in a straight line.The membranous labyrinth in the vestibule is divided into two sac-likestructures, the utricle and the saccule. Each structure in turn containsa small structure called a macula, which is responsible for maintenanceof static equilibrium. The macula consists of sensory hair cells, whichare embedded in a gelatinous mass (similar to the cupula) that coversthe macula. Grains of calcium carbonate, called otoliths, are embeddedon the surface of the gelatinous layer.

When the head is in an upright position, the hairs are straight alongthe macula. When the head tilts, the gelatinous mass and otoliths tiltscorrespondingly, bending some of the hairs on the hair cells of themacula. This bending action initiates a signal impulse to the centralnervous system, which travels via the vestibular branch of thevestibulocochlear nerve, which in turn relays motor impulses to theappropriate muscles to maintain balance.

The cochlea is the portion of the auris interna related to hearing. Thecochlea is a tapered tube-like structure that is coiled into a shaperesembling a snail. The inside of the cochlea is divided into threeregions, which is further defined by the position of the vestibularmembrane and the basilar membrane. The portion above the vestibularmembrane is the scala vestibuli, which extends from the oval window tothe apex of the cochlea and contains perilymph fluid, an aqueous liquidlow in potassium and high in sodium content. The basilar membranedefines the scala tympani region, which extends from the apex of thecochlea to the round window and also contains perilymph. The basilarmembrane contains thousands of stiff fibers, which gradually increase inlength from the round window to the apex of the cochlea. The fibers ofthe basement membrane vibrate when activated by sound. In between thescala vestibuli and the scala tympani is the cochlear duct, which endsas a closed sac at the apex of the cochlea. The cochlear duct containsendolymph fluid, which is similar to cerebrospinal fluid and is high inpotassium.

The organ of Corti, the sensory organ for hearing, is located on thebasilar membrane and extends upward into the cochlear duct. The organ ofCorti contains hair cells, which have hairlike projections that extendfrom their free surface, and contacts a gelatinous surface called thetectorial membrane. Although hair cells have no axons, they aresurrounded by sensory nerve fibers that form the cochlear branch of thevestibulocochlear nerve (cranial nerve VIII).

As discussed, the oval window, also known as the elliptical windowcommunicates with the stapes to relay sound waves that vibrate from thetympanic membrane. Vibrations transferred to the oval window increasespressure inside the fluid-filled cochlea via the perilymph and scalavestibuli/scala tympani, which in turn causes the round window membraneto expand in response. The concerted inward pressing of the ovalwindow/outward expansion of the round window allows for the movement offluid within the cochlea without a change of intra-cochlear pressure.However, as vibrations travel through the perilymph in the scalavestibuli, they create corresponding oscillations in the vestibularmembrane. These corresponding oscillations travel through the endolymphof the cochlear duct, and transfer to the basilar membrane. When thebasilar membrane oscillates, or moves up and down, the organ of Cortimoves along with it. The hair cell receptors in the Organ of Corti thenmove against the tectorial membrane, causing a mechanical deformation inthe tectorial membrane. This mechanical deformation initiates the nerveimpulse that travels via the vestibulocochlear nerve to the centralnervous system, mechanically transmitting the sound wave received intosignals that are subsequently processed by the central nervous system.

Diseases

Autoimmune Inner Ear Disease

Autoimmune inner ear disease (AIED) is one of the few reversible causesof sensorineural hearing loss. It is a rare disorder appearing in bothadults and children that often involves a bilateral disturbance of theaudio and vestibular functions of the auris interna. In many cases, AIEDoccurs without systemic autoimmune symptoms, but up to one-third ofpatients also suffer from a systemic autoimmune illness, such asinflammatory bowel disease, rheumatoid arthritis (Murdin, L. et al(2007) Hearing difficulties are common in patients with rheumatoidarthritis, in Clin Rheumatol, 27(5):637-640), Ankylosing spondylitis,Systemic Lupus Erythematosus (SLE), Sjögren's Syndrome, Cogan's disease,ulcerative colitis, Wegener's granulomatosis and scleroderma. Behçet'sdisease, a multisystem disease, also commonly has audiovestibularproblems. There is some evidence for food-related allergies as a causefor cochlear and vestibular autoimmunity, but there is presently noagreement as to its importance in the aetiology of the disease. Aclassification scheme for AIED has been developed (Harris and Keithley,(2002) Autoimmune inner ear disease, in Otorhinolaryngology Head andNeck Surgery. 91, 18-32).

The immune system normally performs a crucial role in protecting theinner ear from invasive pathogens such as bacteria and viruses. However,in AIED the immune system itself begins to damage the delicate inner eartissues. The inner ear is fully capable of mounting a localized immuneresponse to foreign antigens. When a foreign antigen enters the innerear, it is first processed by immunocompetent cells which reside in andaround the endolymphatic sac. Once the foreign antigen has beenprocessed by these immunocompetent cells, these cells secrete variouscytokines which modulate the immune response of the inner ear. Oneresult of this cytokine release is to facilitate the influx ofinflammatory cells which are recruited from the systemic circulation.These systemic inflammatory cells enter the cochlea via diapedesisthrough the spiral modiolar vein and its tributaries, and begin toparticipate in antigen uptake and deregulation just as it occurs inother parts of the body. Interleukin 1 (IL-1) plays an important role inmodulating the innate (nonspecific) immune response and is a knownactivator of resting T helper cells and B-cells. T helper cells, onceactivated by IL-1, produce IL-2. IL-2 secretion results indifferentiation of pluripotent T-cells into helper, cytotoxic andsuppressor T-cell subtypes. IL-2 also assists T helper cells in theactivation of B lymphocytes and probably plays a pivotal role in theimmunoregulation of the immune response of the vestibular and cochlearregions. IL-2 is within the perilymph of the auris interna as early as 6h after antigen challenge with peak levels at 18 h after antigenchallenge. The perilymphatic levels of IL-2 then dissipate, and it is nolonger present within the perilymph at 120 hours post antigen challenge.

Both IL-1β and tumor necrosis factor-α (TNF-α) may play a key role inthe initiation and amplification of the immune response. IL-1β isexpressed by the fibrocytes of the spiral ligament in the presence oftrauma such as surgical trauma or acoustic trauma in a nonspecificresponse. TNF-α is expressed either by infiltrating systemic cells or byresident cells contained within the endolymphatic sac in the presence ofantigen. TNF-α is released as part of the adaptive (specific) immuneresponse in animal models. When antigen is injected into the aurisinterna of mice, IL-1β and TNF-α are both expressed and a vigorousimmune response occurs. However, when antigen is introduced to the aurisinterna via the cerebral spinal fluid in the absence of trauma, onlyTNF-α is expressed and the immune response in minimal. Importantly,cochlear trauma in isolation also results in a minimal immune response.These results suggest that both the nonspecific and specific componentsof the immune response act in concert in the auris interna to achieve amaximal response.

Accordingly, if the cochlea is traumatized and an antigen is injected(or in the case of autoimmune disease, the patient has immune cellsdirected against inner ear antigens), both the nonspecific and thespecific immune responses can be activated simultaneously. This resultsin the concurrent production of IL-1β as well as TNF-α which causes agreatly amplified level of inflammation leading to substantial damage tothe auris interna. Subsequent experiments in animal models confirm thatan important step in immune-mediated damage requires that the aurisinterna be conditioned by the non-specific innate immune response beforethe specific adaptive immune response can lead to enough inflammation toresult in damage (Hashimoto, Audiol. Neurootol. (2005), 10, 35-43). As aresult, agents which downregulate or block the specific immune response,and in particular the effect of TNF-α, prevent the excessive immuneresponse seen when both the specific and nonspecific immune responsesare simultaneously activated.

As such, some embodiments include the treatment of autoimmune eardisease by administering anti-TNF agents. Etanercept (ENBREL®), ananti-TNF drug, is emerging as a promising agent for treatment ofautoimmune inner ear disease. Additionally, the anti-TNF agentsinfliximab (REMICADE®), adalimumab (HUMIRA®) and golimumab are alsouseful in treatment of autoimmune inner ear disorders. Clinical trialprotocols of systemic treatment of individuals with AIED includeinjections of anti-TNF agents as an injection on a twice-weekly basis.Additional embodiments include the treatment of autoimmune ear diseaseby administering an immunomodulating agent selected from a TACEinhibitor, an IKK inhibitor, a calcineurin inhibitor, a flavonederivative, a toll-like inhibitor, an interleukin-inhibitor, orcombinations thereof.

In other embodiments, included is the treatment of autoimmune oticdisorders with a combination of an immunomodulating agent with anotherpharmaceutical agent including steroids, chemotherapeutic agents,collagen, gamma globulin infusion or other immune modulating drugs.Steroids include, e.g. prednisone or decadron. Chemotherapeutic agents,include, e.g. cytoxan, azathiaprine or methotrexate. Plasmapheresisprocedures are optionally used. Treatment with oral collagen, gammaglobulin infusions or other immune modulating drugs (e.g.beta-interferon, alpha interferon or copaxone) are also optionally usedin combination with an anti-TNF drug.

Endolymphatic Hydrops

Endolymphatic hydrops refers to an increase in the hydraulic pressurewithin the endolymphatic system of the inner ear. The endolymph andperilymph are separated by thin membranes which contain multiple nerves.Fluctuation in the pressure stresses the membranes and the nerves theyhouse. If the pressure is great enough, disruptions may form in themembranes. This results in a mixing of the fluids which can lead to adepolarization blockade and transient loss of function. Changes in therate of vestibular nerve firing often lead to vertigo. Further, theorgan of Corti may also be affected. Distortions of the basilar membraneand the inner and outer hair cells can lead to hearing loss and/ortinnitus.

Causes include metabolic disturbances, hormonal imbalances, autoimmunedisease, and viral, bacterial, or fungal infections. Symptoms includehearing loss, vertigo, tinnitus, and aural fullness. Nystagmus may alsobe present. Treatment includes systemic administration ofbenzodiazepine, diuretics (to decrease the fluid pressure),corticosteroids, and/or anti-bacterial, anti-viral, or anti-fungalagents.

Recurrent Vestibulopathy

Recurrent vestibulopathy is a condition wherein the subject experiencesmultiple episodes of severe vertigo. The episodes of vertigo may lastfor minutes or hours. Unlike Meniere's Disease, it is not accompanied byhearing loss. In some cases it may develop into Meniere's Disease orBenign Paroxysmal Positional Vertigo. Treatment is similar to that ofMeniere's Disease.

Tinnitus

Tinnitus is defined as the perception of sound in the absence of anyexternal stimuli. It may occur in one or both ears, continuously orsporadically, and is most often described as a ringing sound. It is mostoften used as a diagnostic symptom for other diseases. There are twotypes of tinnitus: objective and subjective. The former is a soundcreated in the body which is audible to anyone. The latter is audibleonly to the affected individual. Studies estimate that over 50 millionAmericans experience some form of tinnitus. Of those 50 million, about12 million experience severe tinnitus.

There are several treatments for tinnitus. Lidocaine, administered byIV, reduces or eliminates the noise associated with tinnitus in about60-80% of sufferers. Selective neurotransmitter reuptake inhibitors,such as nortriptyline, sertraline, and paroxetine, have alsodemonstrated efficacy against tinnitus. Benzodiazepines are alsoprescribed to treat tinnitus.

Vertigo

Vertigo is described as a feeling of spinning or swaying while the bodyis stationary. There are two types of vertigo. Subjective vertigo is thefalse sensation of movement of the body. Objective vertigo is theperception that one's surrounding are in motion. It is often accompaniedby nausea, vomiting, and difficulty maintaining balance.

While not wishing to be bound by any one theory, it is hypothesized thatvertigo is caused by an over-accumulation of endolymph. This fluidimbalance results in increased pressure on the cells of the inner earwhich leads to the sensation of movement. The most common cause ofvertigo is benign paroxysmal positional vertigo, or BPPV. It can also bebrought on by a head injury, or a sudden change of blood pressure. It isa diagnostic symptom of several diseases including superior canaldehiscence syndrome and Meniere's disease.

Benign Paroxysmal Positional Vertigo

Benign paroxysmal positional vertigo is caused by the movement of freefloating calcium carbonate crystals (otoliths) from the utricle to oneof the semicircular canals, most often the posterior semicircular canal.Movement of the head results in the movement of the otoliths causingabnormal endolymph displacement and a resultant sensation of vertigo.The episodes of vertigo usually last for about a minute and are rarelyaccompanied by other auditory symptoms.

Mal de Debarquement

Mal de debarquement is a condition which usually occurs subsequent to asustained motion event, for example, a cruise, car trip, or airplaneride. It is characterized by a persistent sense of motion, difficultymaintaining balance, fatigue, and cognitive impairment. Symptoms mayalso include dizziness, headaches, hyperacusis, and/or tinnitus.Symptoms often last in excess of a month. Treatment includesbenzodiazepines, diuretics, sodium channel blockers, and tricyclicantidepressants.

Otitis Externa

Otitis externa (OE), also referred to as swimmer's ear, is aninflammation and/or infection of the external ear. OE is often caused bybacteria in the outer ear, which establish infection following damage tothe skin of the ear canal. Primary bacterial pathogens that cause OE arePseudomonas aeruginosa and Staphylococcus aureus, but the condition isassociated with the presence of many other strains of gram positive andnegative bacteria. OE is also sometimes caused by fungal infection inthe outer ear, including Candida albicans and Aspergillus. Symptoms ofOE include otalgia, swelling, and otorrhea. If the condition progressessignificantly, OE may cause temporary conductive hearing loss as aresult of the swelling and discharge.

Treatment of OE involves eliminating the aggravating pathogen from theear canal and reducing inflammation, which is usually accomplished byadministering combinations of antimicrobial agents, e.g., antibacterialand antifungal agents, with anti-inflammatory agents, e.g., steroids.Typical antibacterial agents for the treatment of OE includeaminoglycosides (e.g., neomycin, gentamycin, and tobramycin), polymyxins(e.g., polymyxin B), fluoroquinolone (e.g., ofloxacin andciprofloxacin), cephalosporins (e.g., cefuroxime, ceflacor, cefprozil,loracarbef, cefindir, cefixime, cefpodoxime proxetil, cefibuten, andceftriaxone), penicillins (e.g., amoxicillin, amoxicillin-clavulanate,and penicillinase-resistant penicillins), and combinations thereof.Typical antifungal agents for the treatment of OE include clotrimazole,thimerasol, M-cresyl acetate, tolnaftate, itraconazole, and combinationsthereof. Acetic acid is also administered to the ear, alone and incombination with other agents, to treat bacterial and fungal infections.When the pain of OE is extremely severe such that it interferes withnormal activity, e.g., sleeping, pain relievers such as topicalanalgesics or oral narcotics may be given until the underlyinginflammation and infection are alleviated.

Otitis Media

Otitis media (OM), which includes acute otitis media (AOM), chronicotitis media, otitis media with effusion (OME), secretory otitis media,and chronic secretory otitis media as examples, is a condition thatpresents in the area between the ear drum and the inner ear. Bacterialinfection accounts for a large percentage of OM cases, with more than40% of cases attributed to Streptococcus pneumoniae infection. However,viruses, as well as other microbes, may also account for OM conditions.

AOM is a condition that is most often purely viral and self-limited.Viral AOM can lead to bacterial otitis media in a very short period oftime, especially in children. Symptoms include, but are not limited to,congestion of the ears, discomfort, pus, and pressure imbalances. OME isa condition characterized by the accumulation of in the middle earspace. It often results from negative pressure produced by alteredEustachian tube function. The accumulation of fluid sometimes leads toconductive hearing impairment (e.g. when it interferes with the abilityof the eardrum to vibrate). If the condition persists, the fluid canincrease in viscosity increasing the likelihood of hearing loss.

Because OM can be caused by a virus, bacteria or both, it is oftendifficult to identify the exact cause and thus the most appropriatetreatment. Treatment options for OM include antibiotics, such aspenicillins (e.g., amoxicillin and amoxicillin-clavulanate), clavulanateacid, trimethoprim-sulfamethoxazole, cephalosporins (e.g., cefuroxime,ceflacor, cefprozil, loracarbef, cefindir, cefixime, cefpodoximeproxetil, cefibuten, and ceftriaxone), macrolides and azalides (e.g.,erythromycin, clarithromycin, and azithromycin), sulfonamides, andcombinations thereof. Surgical intervention is also available, includingmyringotomy, an operation to insert a tympanostomy tube through thetympanic membrane and into the patient's middle ear to drain the fluidand balance the pressure between the outer and middle ear. Antipyreticsand analgesics, including benzocaine, ibuprofen and acetaminophen, mayalso be prescribed to treat accompanying fever or pain effects.

Mastoiditis

Mastoiditis is an infection of the mastoid process, which is the portionof the temporal bone behind the ear. It is typically caused by untreatedacute otitis media. Madtoiditis may be acute or chronic. Symptomsinclude pain, swelling, and tenderness in the mastoid region, as well asotalgia, erythematosus, and otorrhea.

Mastoiditis typically occurs as bacteria spread from the middle ear tothe mastoid air cells, where the inflammation causes damage to the bonystructures. The most common bacterial pathogens are Streptococcuspneumoniae, Streptococcus pyogenes, Staphylococcus aureus, andgram-negative bacilli. Accordingly, antimicrobial agent formulationsdisclosed herein comprising antibacterial agents effective against thebacteria are useful for the treatment of mastoiditis, including acutemastoiditis and chronic mastoiditis.

Bullous myringitis is an infection of the tympanic membrane, caused by avariety of bacteria and viruses, including Mycoplasma bacteria. Theinfection leads to inflammation of the tympanic membrane and nearbycanal, and causes the formation of blisters on the ear drum. The primarysymptom of Bullous myringitis is pain, which may be relieved through theadministration of analgesics. Antimicrobial formulations disclosedherein comprising antibacterial and antiviral agents are useful for thetreatment of Bullous myringitis.

Sensorineural Hearing Loss

Sensorineural hearing loss is a type of hearing loss which results fromdefects (congenital and acquired) in the vestibulocochlear nerve (alsoknown as cranial nerve VIII), or sensory cells of the inner ear. Themajority of defects of the inner ear are defects of otic hair cells.

Aplasia of the cochlea, chromosomal defects, and congenitalcholesteatoma are examples of congenital defects which can result insensorineural hearing loss. By way of non-limiting example, inflammatorydiseases (e.g. suppurative labyrinthitis, meningitis, mumps, measles,viral syphilis, and autoimmune disorders), Meniere's Disease, exposureto ototoxic drugs (e.g. aminoglycosides, loop diuretics,antimetabolites, salicylates, and cisplatin), physical trauma,presbyacusis, and acoustic trauma (prolonged exposure to sound in excessof 90 dB) can all result in acquired sensorineural hearing loss.

If the defect resulting in sensorineural hearing loss is a defect in theauditory pathways, the sensorineural hearing loss is called centralhearing loss. If the defect resulting in sensorineural hearing loss is adefect in the auditory pathways, the sensorineural hearing loss iscalled cortical deafness.

Ototoxicity

Ototoxicity refers to hearing loss caused by a toxin. The hearing lossmay be due to trauma to otic hair cells, the cochlea, and/or the cranialnerve VII. Multiple drugs are known to be ototoxic. Often ototoxicity isdose-dependent. It may be permanent or reversible upon withdrawal of thedrug.

Known ototoxic drugs include, but are not limited to, the aminoglycosideclass of antibiotics (e.g. gentamicin, and amikacin), some members ofthe macrolide class of antibiotics (e.g. erythromycin), some members ofthe glycopeptide class of antibiotics (e.g. vancomycin), salicylic acid,nicotine, some chemotherapeutic agents (e.g. actinomycin, bleomycin,cisplatin, carboplatin and vincristine), and some members of the loopdiuretic family of drugs (e.g. furosemide).

Cisplatin and the aminoglycoside class of antibiotics induce theproduction of reactive oxygen species (ROS). ROS can damage cellsdirectly by damaging DNA, polypeptides, and/or lipids. Antioxidantsprevent damage of ROS by preventing their formation or scavenging freeradicals before they can damage the cell. Both cisplatin and theaminoglycoside class of antibiotics are also thought to damage the earby binding melanin in the stria vascularis of the inner ear.

Salicylic acid is classified as ototoxic as it inhibits the function ofthe polypeptide prestin. Prestin mediates outer otic hair cell motilityby controlling the exchange of chloride and carbonate across the plasmamembrane of outer otic hair cells. It is only found in the outer otichair cells, not the inner otic hair cells. Accordingly, disclosed hereinis the use of controlled release auris-compositions comprisingantioxidants to prevent, ameliorate or lessen ototoxic effects ofchemotherapy, including but not limited to cisplatin treatment,aminoglycoside or salicylic acid administration, or other ototoxicagents.

Excitotoxicity

Excitotoxicity refers to the death or damaging of neurons and/or otichair cells by glutamate and/or similar substances.

Glutamate is the most abundant excitatory neurotransmitter in thecentral nervous system. Pre-synaptic neurons release glutamate uponstimulation. It flows across the synapse, binds to receptors located onpost-synaptic neurons, and activates these neurons. The glutamatereceptors include the NMDA, AMPA, and kainate receptors. Glutamatetransporters are tasked with removing extracellular glutamate from thesynapse. Certain events (e.g. ischemia or stroke) can damage thetransporters. This results in excess glutamate accumulating in thesynapse. Excess glutamate in synapses results in the over-activation ofthe glutamate receptors.

The AMPA receptor is activated by the binding of both glutamate andAMPA. Activation of certain isoforms of the AMPA receptor results in theopening of ion channels located in the plasma membrane of the neuron.When the channels open, Na⁺ and Ca²⁺ ions flow into the neuron and K⁺ions flow out of the neuron.

The NMDA receptor is activated by the binding of both glutamate andNMDA. Activation of the NMDA receptor, results in the opening of ionchannels located in the plasma membrane of the neuron. However, thesechannels are blocked by Mg²⁺ ions. Activation of the AMPA receptorresults in the expulsion of Mg²⁺ ions from the ion channels into thesynapse. When the ion channels open, and the Mg²⁺ ions evacuate the ionchannels, Na⁺ and Ca²⁺ ions flow into the neuron, and K⁺ ions flow outof the neuron.

Excitotoxicity occurs when the NMDA receptor and AMPA receptors areover-activated by the binding of excessive amounts of ligands, forexample, abnormal amounts of glutamate. The over-activation of thesereceptors causes excessive opening of the ion channels under theircontrol. This allows abnormally high levels of Ca²⁺ and Na⁺ to enter theneuron. The influx of these levels of Ca²⁺ and Na⁺ into the neuroncauses the neuron to fire more often, resulting in a rapid buildup offree radicals and inflammatory compounds within the cell. The freeradicals eventually damage the mitochondria, depleting the cell's energystores. Furthermore, excess levels of Ca²⁺ and Na⁺ ions activate excesslevels of enzymes including, but not limited to, phospholipases,endonucleases, and proteases. The over-activation of these enzymesresults in damage to the cytoskeleton, plasma membrane, mitochondria,and DNA of the sensory neuron.

Ramsay Hunt's Syndrome (Herpes Zoster Infection)

Ramsay Hunt's Syndrome is caused by a herpes zoster infection of theauditory nerve. The infection may cause severe ear pain, hearing loss,vertigo, as well as blisters on the outer ear, in the ear canal, as wellas on the skin of the face or neck supplied by the nerves. Facialmuscles may also become paralyzed if the facial nerves are compressed bythe swelling. Hearing loss may be temporary or permanent, with vertigosymptoms usually lasting from several days to weeks.

Treatment of Ramsay Hunt's syndrome includes administration of antiviralagents, including acyclovir. Other antiviral agents include famciclovirand valacyclovir. Combination of antiviral and corticosteroid therapymay also be employed to ameliorate herpes zoster infection. Analgesicsor narcotics may also be administered to relieve the pain, and diazepamor other central nervous system agents to suppress vertigo. Capsaicin,lidocaine patches and nerve blocks are optionally used. Surgery may alsobe performed on compressed facial nerves to relieve facial paralysis.

Labyrinthitis

Labyrinthitis is an inflammation of the labyrinths of the ear whichcontain the vestibular system of the inner ear. Causes includebacterial, viral, and fungal infections. It may also be caused by a headinjury or allergies. Symptoms of labyrinthitis include difficultymaintaining balance, dizziness, vertigo, tinnitus, and hearing loss.Recovery may take one to six weeks; however, chronic symptoms may bepresent for years.

There are several treatments for labyrinthitis. Prochlorperazine isoften prescribed as an antiemetic. Serotonin-reuptake inhibitors havebeen shown to stimulate new neural growth within the inner ear.Additionally, treatment with antibiotics is prescribed if the cause is abacterial infection, and treatment with corticosteroids and antiviralsis recommended if the condition is caused by a viral infection.

Kinetosis

Kinetosis, also known as motion sickness, is a condition in which thereis a disconnection between visually perceived movement and thevestibular system's sense of movement. Dizziness, fatigue, and nauseaare the most common symptoms of kinetosis. Dimenhydrinate, cinnarizine,and meclizine are all systemic treatments for kinetosis. Additionally,benzodiazepines and antihistamines have demonstrated efficacy intreating kinetosis.

Meniere's Disease

Meniere's Disease is an idiopathic condition characterized by suddenattacks of vertigo, nausea and vomiting that may last for 3 to 24 hours,and may subside gradually. Progressive hearing loss, tinnitus and asensation of pressure in the ears accompanies the disease through time.The cause of Meniere's disease is likely related to an imbalance ofinner ear fluid homeostasis, including an increase in production or adecrease in reabsorption of inner ear fluid.

Studies of the vasopressin (VP)-mediated aquaporin 2 (AQP2) system inthe inner ear suggest a role for VP in inducing endolymph production,thereby increasing pressure in the vestibular and cochlear structures.VP levels were found to be upregulated in endolymphatic hydrops(Meniere's Disease) cases, and chronic administration of VP in guineapigs was found to induce endolymphatic hydrops. Treatment with VPantagonists, including infusion of OPC-31260 (a competitive antagonistof V₂-R) into the scala tympani resulted in a marked reduction ofMeniere's disease symptoms. Other VP antagonists include WAY-140288,CL-385004, tolvaptan, conivaptan, SR 121463A and VPA 985. (Sanghi et al.Eur. Heart J. (2005) 26:538-543; Palm et al. Nephrol. Dial Transplant(1999) 14:2559-2562).

Other studies suggest a role for estrogen-related receptor β/NR3B2(ERR/Nr3b2) in regulating endolymph production, and therefore pressurein the vestibular/cochlear apparatus. Knock-out studies in micedemonstrate the role of the polypeptide product of the Nr3b2 gene inregulating endolymph fluid production. Nr3b2 expression has beenlocalized in the endolymph-secreting strial marginal cells andvestibular dark cells of the cochlea and vestibular apparatus,respectively. Moreover, conditional knockout of the Nr3b2 gene resultsin deafness and diminished endolymphatic fluid volume. Treatment withantagonists to ERR/Nr3b2 may assist in reducing endolymphatic volume,and thus alter pressure in the auris interna structures.

Other treatments may be aimed at dealing with the immediate symptoms andprevention of recurrence. Low-sodium diets, avoidance of caffeine,alcohol, and tobacco have been advocated. Medications that maytemporarily relieve vertigo attacks include antihistamines (includingmeclizine and other antihistamines), and central nervous system agents,including barbiturates and/or benzodiazepines, including lorazepam ordiazepam. Other examples of drugs that may be useful in relievingsymptoms include muscarinic antagonists, including scopolamine. Nauseaand vomiting may be relieved by suppositories containing antipsychoticagents, including the phenothiazine agent prochlorperazine.

Surgical procedures that have been used to relieve symptoms include thedestruction of vestibular and/or cochlear function to relieve vertigosymptoms. These procedures aim to either reduce fluid pressure in theinner ear and/or to destroy inner ear balance function. An endolymphaticshunt procedure, which relieves fluid pressure, may be placed in theinner ear to relieve symptoms of vestibular dysfunction. Othertreatments include gentamicin application, which when injected into theeardrum destroys sensory hair cell function, thereby eradicating innerear balance function. Severing of the vestibular nerve may also beemployed, which while preserving hearing, may control vertigo.

Meniere's Syndrome

Meniere's Syndrome, which displays similar symptoms as Meniere'sdisease, is attributed as a secondary affliction to another diseaseprocess, e.g. thyroid disease or inner ear inflammation due to syphilisinfection. Meniere's syndrome, thus, are secondary effects to variousprocess that interfere with normal production or resorption ofendolymph, including endocrine abnormalities, electrolyte imbalance,autoimmune dysfunction, medications, infections (e.g. parasiticinfections) or hyperlipidemia. Treatment of patients afflicted withMeniere's Syndrome is similar to Meniere's Disease.

Microvascular Compression Syndrome

Microvascular compression syndrome (MCS), also called “vascularcompression” or “neurovascular compression”, is a disorder characterizedby vertigo and tinnitus. It is caused by the irritation of Cranial NerveVII by a blood vessel. Other symptoms found in subjects with MCSinclude, but are not limited to, severe motion intolerance, andneuralgic like “quick spins.” MCS is treated with carbamazepine,TRILEPTAL®, and baclofen. It can also be surgically treated.

Vestibular Neuronitis

Vestibular neuronitis, or vestibular neuropathy, is an acute, sustaineddysfunction of the peripheral vestibular system. It is theorized thatvestibular neuronitis is caused by a disruption of afferent neuronalinput from one or both of the vestibular apparatuses. Sources of thisdisruption include viral infection and acute localized ischemia of thevestibular nerve and/or labyrinth.

The most significant finding when diagnosing vestibular neuronitis isspontaneous, unidirectional, horizontal nystagmus. It is oftenaccompanied by nausea, vomiting, and vertigo. It is, however, generallynot accompanied by hearing loss or other auditory symptoms.

There are several treatments for vestibular neuronitis. H1-receptorantagonists, such as dimenhydrinate, diphenhydramine, meclizine, andpromethazine, diminish vestibular stimulation and depress labyrinthinefunction through anticholinergic effects. Benzodiazepines, such asdiazepam and lorazepam, are also used to inhibit vestibular responsesdue to their effects on the GABA_(A) receptor. Anticholinergics, forexample scopolamine, are also prescribed. They function by suppressingconduction in the vestibular cerebellar pathways. Finally,corticosteroids (i.e. prednisone) are prescribed to ameliorate theinflammation of the vestibular nerve and associated apparatus.

Acoustic Trauma

Hearing loss may also occur from prolonged exposure to loud noises, suchas loud music, heavy equipment or machinery, airplanes or gunfire. Thehearing loss occurs as result of destruction of hair cell receptors inthe inner ear. This hearing loss is often accompanied by tinnitus.Permanent damage to hearing loss is often diagnosed.

Although there is currently no treatment for noise-induced hearing loss,several treatment regimens have been experimentally developed, includingtreatment with insulin-like growth factor 1 (IGF-1). (Lee et al. Otol.Neurotol. (2007) 28:976-981).

Presbycusis

Presbycusis, or age-related hearing loss, occurs as a part of normalaging, and occurs as a result of degeneration of the receptor cells inthe spiral organ of Corti in the inner ear. Other causes may also beattributed to a decrease in a number of nerve fibers in thevestibulocochlear nerve, as well as a loss of flexibility of the basilarmembrane in the cochlea. There is currently no known cure for permanenthearing damage as a result of presbycusis or excessive noise.

Hereditary Disorders

Hereditary disorders, including Scheibe, Mondini-Michelle,Waardenburg's, Michel, Alexander's ear deformity, hypertelorism,Jervell-Lange Nielson, Refsum's and Usher's syndromes, are found inapproximately 20% of patients with sensorineural hearing loss.Congenital ear malformations may result from defects in the developmentof the membranous labyrinthine, the osseous labyrinthine, or both. Alongwith profound hearing loss and vestibular function abnormalities,hereditary deformities may also be associated with other dysfunctions,including development of recurring meningitis, cerebral spinal fluid(CSF) leaks, as well as perilymphatic fistulas. Treatment of chronicinfections may be necessitated in hereditary disorder patients.

Otosclerosis

Bone remodeling is a life long process where old bone is removed fromthe skeleton (bone resorption) and new bone is added (bone formation).These processes also control the reshaping or replacement of bone duringgrowth and following injuries. An imbalance in the regulation of boneresorption and bone formation results in many bone diseases such asotosclerosis.

Bone remodeling involves erosion of bone by osteoclasts, which isfollowed by osteoblasts refilling the resorption sites. Osteoclastsadhere to bone and remove it by acidification and proteolytic digestion.Tunnels are then formed in the bone, and the tunnels function aspathways for osteoblasts and small blood vessels. Fresh layers ofosteoid, a cement-like substance, are deposited in the tunnels byosteoblasts and this eventually becomes new bone matrix.

Osteoclasts secrete various enzymes that act in dissolution of bonematerial. For example, tartrate resistant acid phosphatase (TRACP)decalcifies the bone, while cathepsin K digests the bone matrixproteins. The modulation of bone homeostasis is controlled by severalfactors. These factors can be divided into three groups: 1) thoseinfluencing the activity of osteoblasts, e.g., parathyroid hormone (PTH)or 1, 25-dihydroxyvitamin D₃, 2) those affecting osteoclast precursorsor osteoclasts, e.g., osteoblasts produce osteoprotegerin (OPG) andRANKL which play a role in osteoclast differentiation; and 3) those withbipotential effects (e.g., TGF-β can either inhibit or promoteosteoclast differentiation by acting on osteoblasts or osteoclasts,respectively).

“Otosclerosis” is localized bone remodeling within the otic capsule ofthe human temporal bone. Three ossicles, the malleus, incus and stapesconduct sound in the middle ear from the tympanic membrane to the ovalwindow of the inner ear. The lesions in the bony structures of the earbegin by softening/resorption of stable otic capsule bone (“activephase”), followed by a reparative phase with bone deposition. There isan abundance of osteoclasts in the bone in the active phase ofotosclerosis. Lamellar bone is removed by the osteoclasts and replacedby woven spongiotic bone of greater thickness and vascularity. Thisspongiotic phase (“otospongiosis”) produces its most significant effectupon the inner ear. Otospongiosis can produce symptoms of progressivesensorineural hearing loss, tinnitus, dizziness, and Meniere's syndrome.The sclerotic phase may still have elements of active demineralizationof the bone around the inner ear, but also with a harder or scleroticelement to it. A visual exam can not determine whether the bone isspongiotic or sclerotic. To the naked eye it appears to be hard bone andis therefore called otosclerosis, although it may be in its active phaseand more aptly called otospongiosis. By common usage, both phases ofthis disorder are referred to as otosclerosis.

Conductive hearing loss in otosclerosis is caused by two main sites ofinvolvement of the sclerotic (or scar-like) lesions. The abnormal bonegrowth fixates the stapes footplate to the oval window of the cochlea.This impairs movement of the stapes and therefore transmission of soundinto the inner ear (“ossicular coupling”). Additionally the cochlearround window can also become sclerotic, and impair movement of soundpressure waves through the inner ear (“acoustic coupling”). Otosclerosismay also cause a sensorineural hearing loss, i.e. nerve fibers orhearing hair cells of the cochlea may be damaged in patients withotosclerosis. The release of hydrolytic enzymes into the inner earstructures by the spongiotic lesions may play a role in the loss ofcochlear hearing cells.

Genetic factors play a role in the aetiology of the disease but measlesvirus infection and autoimmunity may also play contributing roles.Treatment of otosclerosis includes surgery to remove the fixated stapesbone, called a stapedectomy. Disclosed herein are non-surgical methodsfor treatment of otosclerosis.

Cholesteatoma

A cholesteatoma is a hyperproliferative cyst often found in the middleear. Cholesteatoma are classified as congenital or acquired. Acquiredcholesteatomas result from retraction of the ear drum (primary) and/or atear in the ear drum (secondary).

The most common primary cholesteatoma results from the pars flaccidaretracting into the epitympanum. As the pars flaccida continues toretract, the lateral wall of the epitympanum slowly erodes. Thisproduces a defect in the lateral wall of the epitympanum that slowlyexpands. A less common type of primary acquired cholesteatoma resultsfrom the retraction of the posterior quadrant of the tympanic membraneretracts into the posterior middle ear. As the tympanic membraneretracts, squamous epithelium envelops the stapes and retracts into thesinus tympani. Secondary cholesteatomas result from injury to thetympanic membrane (e.g. a perforation resulting from otitis media;trauma; or a surgically-induced injury).

Complications associated with a growing cholesteatoma include injury tothe osteoclasts and, in some cases, deterioration of the thin bone layerseparating the top of the ear from the brain. Damage to the osteoclastsresults from the persistent application of pressure to the bonesresulting from the expansion of the cholesteatoma. Additionally, thepresence of multiple cytokines (e.g. TNF-α, TGF-β1, TGF-β2, Il-1, andIL-6) in the epithelium of the cholesteatoma can result in furtherdegradation of the surrounding bones.

Patients with a cholesteatoma often present with earache, hearing loss,mucopurulent discharge, and/or dizziness. Physical examination canconfirm the presence of a cholesteatoma. Symptoms which can beidentified upon physical examination include damage to the ossicles, anda canal filled with mucopus and granulation tissue.

There is currently no effective medical therapy for cholesteatomas. As acholesteatoma has no blood supply, it cannot be treated with systemicantibiotics. Topical administration of antibiotics often fails to treata cholesteatoma.

Reperfusion Injury

Ischemia is a condition characterized by a lack of, or an inadequateamount of, blood supply to an organ. Ischemia often results inirreversible damage to tissue (e.g. from necrosis) due to the resultantlack of, or insufficiency of, oxygen. Irreversible damage to an organcan arise from as little as 20 minutes of complete oxygen deprivation.

Ischemia is a sequelae of disorders such as, but not limited to, heartdiseases, transient ischemic attacks, cerebrovascular accidents,ruptured arteriovenous malformations, peripheral artery occlusivedisease, stroke, and head injury. Cochlear ischemia results from, amongother causes, occlusion the vertebral arteries and/or cerebral arteries,stroke, cardiovascular disease, and acoustic trauma.

Reperfusion is the restoration of normal blood supply to an organfollowing ischemia. In certain instances, reperfusion results inadditional damage to tissues already damaged due to an ischemic episodeand surrounding tissues (reperfusion injury). In certain instances,reperfusion injury results from the white blood cells in the restoredblood supply reacting to the tissue damaged by ischemia. Additionally,in certain instances, the complement system (which is carried in therestored blood supply) damages tissue injured by ischemia, and thesurrounding tissues (e.g. by the MAC, facilitation of opsonization, andthe presence of multiple anaphylatoxins). In certain instances,depletion or inactivation of the complement system amelioratesreperfusion injury.

Labyrinthitis Ossificans

Labyrinthitis ossificans (aka labyrinthine ossification, cochlearossification, or vestibular ossification) is a condition characterizedby the development or growth of bone (e.g. the deposition of osteoidfollowed by mineralization and reorganization) into the spaces withinthe lumen of the boney labyrinth. This ossification of the lumen of thelabyrinth leads to the destruction of the endolymphatic andperilymphatic spaces, deafness, and dysfunction of the vestibularsystem. In the cochlear area of the labyrinth, the scala tympani is mostoften the site of ossification.

It is most often an inflammatory response resulting from AIED or thepresence of a pathogen (e.g. S. pneumoniae and H. influenzae) that leadsto the ossification of the labyrinth. With regards to pathogenicinfections, complete ossification will occur within a few months ofinfection. In certain instances, depletion or inactivation of thecomplement system ameliorates the development of labyrinthitisossificans. Additionally, disorders such as vascular obstruction of thelabyrinthine artery, temporal bone trauma, leukemia, and tumors of thetemporal bone can also result in the development of labyrinthitisossificans.

Treatment of an underlying pathogenic infection (e.g. meningitis, otitismedia, and labyrinthitis) fully or partially prevents the development oflabyrinthitis ossificans. Further, deactivation of the complement systemalso fully or partially prevents the development of labyrinthitisossificans. However, if the disease is allowed to progress surgicalremoval of the excess bone is a current remedy. Additionally, in severecases of labyrinthitis ossificans, cochlear implants are required torestore hearing.

Pharmaceutical Agents

Provided herein are otic structure modulating agent compositions orformulations that modulate destroyed, stunted, malfunctioning, damaged,fragile or missing otic structures. In some embodiments, the oticstructure modulating agent compositions or formulations participate inthe degradation of destroyed, stunted, malfunctioning, damaged, fragile,or missing otic structures. In some embodiments, the otic structuremodulating agent compositions or formulations participate in theconstruction of destroyed, stunted, malfunctioning, damaged, fragile, ormissing otic structures. In some embodiments, the otic structuremodulating agent is an agonist of an otic structure modulating target, apartial agonist of an otic structure modulating target, an antagonist ofan otic structure modulating target, a partial antagonist of an oticstructure modulating target, an inverse agonist of an otic structuremodulating target, a competitive antagonist of an otic structuremodulating target, a neutral antagonist of an otic structure modulatingtarget, an orthosteric antagonist of an otic structure modulatingtarget, an allosteric antagonist of an otic structure modulating target,a positive allosteric modulator of an otic structure modulating targetor combinations thereof.

Provided herein are innate immune system modulating compositions orformulations that modulate a component of the innate immune system. Insome embodiments, the innate immune system modulating agent increasesthe activity of a component of the innate immune system. In someembodiments, the innate immune system modulating agent inhibits(partially or fully) the activity of a component of the innate immunesystem. In some embodiments, the innate immune system is the complementsystem.

Otic and vestibular disorders have causes and symptoms that areresponsive to the pharmaceutical agents disclosed herein, or otherpharmaceutical agents. Otic structure modulating agent or innate immunesystem modulating agents which are not disclosed or exemplified hereinbut which ameliorate or eradicate otic disorders are expressly includedand intended within the scope of the embodiments presented.

Moreover, pharmaceutical agents which have been previously shown to betoxic, harmful or non-effective during systemic or localized applicationin other organ systems, for example through toxic metabolites formedafter hepatic processing, toxicity of the drug in particular organs,tissues or systems, through high levels needed to achieve efficacy,through the inability to be released through systemic pathways orthrough poor pK characteristics, are useful in some embodiments herein.Accordingly, pharmaceutical agents which have limited or no systemicrelease, systemic toxicity, poor pK characteristics or combinationsthereof are contemplated within the scope of the embodiments disclosedherein.

The otic structure modulating agent or innate immune system modulatingagent formulations disclosed herein are optionally targeted directly tootic structures where treatment is needed; for example, one embodimentcontemplated is the direct application of the otic structure modulatingagent or innate immune system modulating agent formulations disclosedherein onto the round window membrane or the crista fenestrae cochlea ofthe auris interna, allowing direct access and treatment of the aurisinterna, or inner ear components. In other embodiments, the oticstructure modulating agent or innate immune system modulating agentformulation disclosed herein is applied directly to the oval window. Inyet other embodiments, direct access is obtained through microinjectiondirectly into the auris interna, for example, through cochlearmicroperfusion. Such embodiments also optionally comprise a drugdelivery device, wherein the drug delivery device delivers the oticstructure modulating agent or innate immune system modulating agentformulations through use of a needle and syringe, a pump, amicroinjection device, an in situ forming spongy material or anycombination thereof.

Some pharmaceutical agents, either alone or in combination, areototoxic. For example, some chemotherapeutic agents, includingactinomycin, bleomycin, cisplatin, carboplatin and vincristine; andantibiotics, including erythromycin, gentamicin, streptomycin,dihydrostreptomycin, tobramycin, netilmicin, amikacin, neomycin,kanamycin, etiomycin, vancomycin, metronidizole, capreomycin, are mildlyto very toxic, and affect the vestibular and cochlear structuresdifferentially. However, in some instances, the combination of anototoxic drug, for example cisplatin, in combination with anotoprotectant is protective by lessening the ototoxic effects of thedrug. Moreover, the localized application of the potentially ototoxicdrug also lessens the toxic effects that would otherwise occur throughsystemic application through the use of lower amounts with maintainedefficacy, or the use of targeted amounts for a shorter period of time.

Moreover, some pharmaceutical excipients, diluents or carriers arepotentially ototoxic. For example, benzalkonium chloride, a commonpreservative, is ototoxic and therefore potentially harmful ifintroduced into the vestibular or cochlear structures. In formulating acontrolled release otic structure modulating agent or innate immunesystem modulating agent formulation, it is advised to avoid or combinethe appropriate excipients, diluents or carriers to lessen or eliminatepotential ototoxic components from the formulation, or to decrease theamount of such excipients, diluents or carriers. Optionally, acontrolled release otic structure modulating agent or innate immunesystem modulating agent formulation includes otoprotective agents, suchas antioxidants, alpha lipoic acid, calcium, fosfomycin or ironchelators, to counteract potential ototoxic effects that may arise fromthe use of specific therapeutic agents or excipients, diluents orcarriers.

Otic Structure Enhancing Agents

Contemplated for use with the formulations disclosed herein are agentsfor treating or ameliorating hearing loss or reduction resulting fromdestroyed, stunted, malfunctioning, damaged, fragile or missing oticstructures (e.g. tissues, membranes, cells, cartilage, bone).Accordingly, some embodiments incorporate the use of molecularcomponents of otic structures. In certain instances, the molecularcomponents of otic structures are utilized by a body to replace orrepair destroyed, stunted, malfunctioning, damaged, fragile or missingotic structures. In some embodiments, the components of otic structuresare polypeptides or polyglycans. In some embodiments, the components ofotic structures are actin, aggrecan, chondroitin, collagen, decorin,dermatan sulfate, elastin, fibrinogen, fibronectin, fimbrin, glialfibrillary acidic protein, heparan sulfate, hyaluronic acid, keratin,laminin, nestin, NF-L, NF-M, NF—H, NF66, peripherin, α-tubulin,β-tubulin, villin, vimentin, whirlin, or combinations thereof.

In certain instances, actin is a molecular component of a cytoskeleton,stereocilia, and/or an actoclampin motor. In certain instances, aggrecanis a molecular component of cartilage. In certain instances, chondroitinis a molecular component of cartilage. In certain instances, collagen isa molecular component of a major component of the extracellular matrix,cartilage, ligaments, tendons, bone, and/or blood vessels. In certaininstances, decorin is a molecular component of the extracellular matrix,and/or connective tissue. In certain instances, dermatan sulfate is amolecular component of epithelial tissue. In certain instances, elastinis a molecular component of connective tissue. In certain instances,fibrinogen is a molecular component of blood. In certain instances,fibronectin is a molecular component of cytoskeleton and/or theextracellular matrix. In certain instances, fimbrin is a molecularcomponent of a cytoskeleton, stereocilia, and/or an actoclampin motor.In certain instances, glial fibrillary acidic protein is a molecularcomponent of glial cells. In certain instances, heparan sulfate is amolecular component of epithelial tissue and/or cytoskeleton. In certaininstances, hyaluronic acid is a molecular component of connective,epithelial, and neural tissues, and/or the extracellular matrix. Incertain instances, keratin is a molecular component of epitheliumtissue. In certain instances, laminin is a molecular component of theextracellular matrix. In certain instances, α-tubulin is a molecularcomponent of cytoskeletons. In certain instances, nestin is a molecularcomponent of neurons. In certain instances, NF-L is a molecularcomponent of neurons. In certain instances, NF-M is a molecularcomponent of neurons. In certain instances, NF—H is a molecularcomponent of neurons. In certain instances, NF66 is a molecularcomponent of neurons. In certain instances, peripherin is a molecularcomponent of neurons. In certain instances, vimentin is a molecularcomponent of neurons. In certain instances, β-tubulin is a molecularcomponent of cytoskeletons. In certain instances, villin is a molecularcomponent of cytoskeleton, stereocilia, and/or an actoclampin motor. Incertain instances, whirlin is a molecular component of stereocilia.

In certain instances, an otic structure enhancing agent is hyaluronicacid (e.g. Restylane®, Perlane®, (Q-Med AB, Sweden and MedicisAesthetics)), Juvederm®. In some instances hyaluronic acid is obtainedfrom pathogens (e.g., streptococcus bacteria). In some instances,hyaluronic acid is obtained from avian sources (e.g. Hyalofomm®,(Genzyme Corporation)). In some instances, an otic structure enhancingagent is collagen (e.g., Zyplast®, Zyderm®, Cosmoderm®, Cosmoplast®(Inamed Corporation)). In some instances collagen is obtained fromhumans. In some instances collagen is obtained from animal sources.

Otic Bone Remodeling Agents

Contemplated for use with the formulations disclosed herein are agentsfor treating or ameliorating hearing loss, and/or a balance disorderresulting from destroyed, stunted, malfunctioning, damaged, fragile ormissing otic bone structures (e.g. otosclerosis). Further contemplatedfor use with the formulations disclosed herein are agents for modulatingotic bone remodeling. In some embodiments, the modulator of boneremodeling is a modulator of osteoblasts or osteoclasts. In someinstances, the modulator of bone remodeling is a hormone. In certaininstances, the modular of bone remodeling is a bisphosphonate. In someembodiments, the modulator of bone remodeling is a matrixmetalloproteinase inhibitor. In some instances, the modulator of boneremodeling is an adenylyl cyclase (AC) modulator. In certain instances,the modulator of bone remodeling is a protease inhibitor. In someembodiments, the modulator of bone remodeling is a modulator oftartarate resistant acid phosphatase (TRACP). In some instance, themodulator of bone remodeling is an estrogen receptor modulator. In someembodiments, the modulator of bone remodeling is a PPAR γ modulator. Incertain instances, the modulator of bone remodeling is an HMG-CoAreductase inhibitor. In some embodiments, the modulator of boneremodeling is a statin. In some instances, the modulator of boneremodeling is a carbonic anhydrase inhibitor. In some embodiments, themodulator of bone remodeling is a modulator of the receptor activator ofnuclear κB ligand (RANKL). In certain instances, the modulator of boneremodeling is a COX-2 inhibitor. In some embodiments, the modulator ofbone remodeling is an inhibitor of protein prenylation. In certaininstances, the modulator of bone remodeling is a 5-lipoxygenaseinhibitor. In some instances, the modulator of bone remodeling is aninhibitor of TNF. In some embodiments, the modulator of bone remodelingis an inhibitor of leukotrienes. In some embodiments, the modulator ofbone remodeling is a cytokine modulator. In some instances, themodulator of bone remodeling is an inhibitor of TSG-6. In someembodiments, the modulator of bone remodeling is a modulator of TGF β.In some instances, the modulator of bone remodeling is a nitiric oxidesynthase inhibitors. In some embodiments, the modulator of boneremodeling is an acetylcysteine. In certain embodiments, the modulatorof bone remodeling is a modulator of aromatases. In some instances, themodulator of bone remodeling is a strontium-based compound as disclosedin WO/2008/027880, which is incorporated by reference herein for thesubject matter disclosed.

Otic Structure Degrading Agents

Contemplated for use with the formulations disclosed herein are agentsfor treating or ameliorating hearing loss, and/or a balance disorderresulting from destroyed, stunted, malfunctioning, damaged, fragile ormissing otic structures (e.g. Meniere's disease, endolymphatic hydrops,vestibular neuronitis). Further contemplated for use with theformulations disclosed herein are agents which facilitate thepenetration of an otic active agent into the middle and/or inner ear bydegrading barriers (e.g. cells, lipid matrix, extracellular matrix,desmosome). Further contemplated for use with the formulations disclosedherein are agents that act as anti-microbial agents (e.g. agents thatinhibit the adhesion of microbes to otic structures). Additionally,contemplated for use with the formulations disclosed herein are agentsfor treating or ameliorating hearing loss or reduction resulting fromthe accumulation of fluid (e.g. mucus and pus) and/or cerumen within theear (e.g. the outer ear, middle ear, and inner ear). Accordingly, someembodiments incorporate the use of an agent that participates in thedegradation an otic structure (e.g. a neuron, a membrane, cartilage,bone, endolymph, perilymph).

In some embodiments, the otic structure modulating agent is an oticstructure degrading agent. In some embodiments, the otic structuredegrading agent degrades bone. In some embodiments, the otic structuredegrading agent degrades cartilage. In some embodiments, the oticstructure degrading agent degrades a neuron. In some embodiments, theotic structure degrading agent degrades a membrane (e.g., a tympanicmembrane). In some embodiments, the otic structure degrading agentdegrades endolymph. In some embodiments, the otic structure degradingagent degrades perilymph. In some embodiments, the otic structuredegrading agent degrades liquor puris (i.e., pus).

In some embodiments, the agent that participates in the degradation ofan otic structure is an alcohol or alkanol (e.g. decanol, and ethanol),an essential oil (e.g. basil oil, palmarosa oil, petitgrain oil, andthyme oil), a fatty acid (capric acid, lauric acid, linoleic acid,myristic acid, and oleic acid), a glycol (e.g. polyethylene glycol, andproplyene glycol), laurocapram, a pyrrolidone (e.g. 2-pyrrolidone,N-methylpyrrolidone, and N-(2-hydroxyethyl)-2-pyrrolidone), a sulfoxide(e.g. DMSO, n-Decylmethyl Sulfoxide), a surfactant (e.g. Span 80, sodiumlauryl sulfate, Tween 20, and Tween 80), a bile salt (e.g. sodiumglycocholate, sodium deoxycholate, sodium taurocholate, sodiumtaurodihydrofusidate, sodium glycodihydrofusidate and the like), achelating agent (e.g. EDTA, citric acid, salicylates and the like), anenzyme, or combinations thereof. In some embodiments, the enzyme is aprotease, a glycosidase, an actinase, a chondroitinase, a collagenase, adermatanase, an elastase, a gelatinase, a heparanase, a hyaluronidase, akeratinase, a lipase, a metallproteinase (e.g. matrix metallproteinase),a staphylokinase, a streptokinase, chymotrypsin, endopeptidase V8,trypsin, thermolysin, pepsin, plasmin, or combinations thereof.

In some embodiments, the enzyme is an actinase (e.g. fragilysin). Incertain instances, administration or application of an actinase degradesan actin.

In some embodiments, the enzyme degrades chondroitin, dermatan, and/orhyaluronic acid. In certain instances, administration or application ofa chondroitinase (e.g. N-acetylgalactosamine-6-sulfatase;N-acetylgalactosamine-4-sulfatase; Chondroitin AC lyase; Chondroitin Blyase; Chondroitin-sulfate-ABC endolyase; and Chondroitin-sulfate-ABCexolyase) degrades a chondroitin, dermatan, and/or a hyaluronic acid. Incertain instances, administration or application of a dermatanasedegrades a dermatan sulfate. In certain instances, administration orapplication of a hyaluronidase (hyaluronoglucosaminidase;hyaluronoglucuronidase; hyaluronate lyase) degrades a hyaluronic acid,condroitin, and/or dermatan. In certain instances, hyaluronidasedegrades fluids that accumulate in tympanostomy tubes and/or mucus thatis present in the middle ear.

In certain instances, a glycosidase degrades mucus that is present inthe middle ear.

In some embodiments, the enzyme is a heparanase (e.g.heparan-alpha-glucosaminide N-acetyltransferase;N-acetylglucosamine-6-sulfatase; and iduronate-2-sulfatase). In certaininstances, administration or application of a heparanase degrades aheparan sulfate. In certain instances, a heparinase degrades heparinsulfate moieties from nasopharyngeal epithelia cells resulting in thedetachment of pneumococci from nasopharyngeal epithelia cells.

In some embodiments, the enzyme is a keratinase (e.g. peptidase K; andcandidapepsin). In certain instances, administration or application of akeratinase degrades a keratin.

In some embodiments, the enzyme is a lipase (e.g. triacylglycerollipase; acylglycerol lipase; lipoprotein lipase; and hormone-sensitivelipase). In certain instances, administration or application of a lipasedegrades a lipid. In certain instances, administration or application ofa lipase degrades cerumen.

In some embodiments, the enzyme is a metallproteinase. In certaininstances, administration or application of a metallproteinase degradesa polypeptide. In some embodiments, the metallproteinase is a matrixmetalloproteinase or thermolysin. In some embodiments, the matrixmetalloproteinase is a collagenase, a gelatinase, a stromelysin, anMT1-MMP, an MT2-MMP, an MT3-MMP, an MT4-MMP, an MT5-MMP, and an MT6-MMP.In certain instances, administration or application of a collagenasedegrades a collagen. In certain instances, administration or applicationof a collagenase degrades cerumen. In certain instances, administrationor application of a gelatinase degrades a gelatin and/or a type IVcollagen. In certain instances, administration or application of astromelysin degrades an extracellular matrix protein. In certaininstances, administration or application of thermolysin degrades apolypeptide by cleaving the peptide chain at a hydrophobic amino acid.

In some embodiments, the enzyme is plasmin, a plasminogen activator,and/or combinations thereof. In certain instances, administration orapplication of a plasmin degrades a fibrin, a fibronectin, athrombospondin, a laminin, and a von Willebrand factor. In someembodiments, the plasminogen activator is staphylokinase, streptokinase,and/or combinations thereof. In certain instances, administration orapplication of a staphylokinase activates a plasminogen to form aplasmin. In certain instances, administration or application of astreptokinase activates a plasminogen to form a plasmin. In certaininstances, plasmin degrades basement membranes.

In some embodiments, the enzyme is a serine protease. In certaininstances, administration or application of a serine protease degrades apolypeptide. In certain instances, administration or application of aserine protease degrades cerumen. In some embodiments, the serineprotease is chymotrypsin, elastase, trypsin, and/or V8 protease. Incertain instances, administration or application of chymotrypsindegrades a polypeptide by cleaving the peptide chain at the carboxylside of a tyrosine, a tryptophan, and a phenylalanine. In certaininstances, administration or application of an elastase degrades anelastin. In certain instances, administration or application of trypsindegrades a polypeptide by cleaving the peptide chain at the carboxylside of a lysine or an arginine. In certain instances, administration orapplication of V8 protease degrades a polypeptide by cleaving thepeptide chain at the carboxyl side of an aspartic acid and/or glutamicacid.

In some embodiments, the enzyme is an aspartic protease. In certaininstances, administration or application of an aspartic proteasedegrades a polypeptide. In certain instances, administration orapplication of an aspartic protease degrades cerumen. In someembodiments, the aspartic protease is pepsin, plasmepsin, orcombinations thereof. In certain instances, administration orapplication of a pepsin degrades a polypeptide by cleaving the peptidechain at carboxyl side of an aromatic amino acid such as phenylalanineand tyrosine. In certain instances, administration or application of aplasmepsin degrades a polypeptide (e.g. hemoglobin) by cleaving thepeptide chain at two aspartic acid residues.

In certain instances, the otic structure degrading agent is ahyaluronidase. In certain instances, a hyaluronidase is a human orbovine hyaluronidase. In some instances, a hyaluronidase is a humanhyaluronidase (e.g., hyaluronidase found in human sperm, PH20(Halozyme), Hyelenex® (Baxter International, Inc.)). In some instances,a hyaluronidase is a bovine hyaluronidase (e.g., bovine testicularhyaluronidase, Amphadase® (Amphastar Pharmaceuticals), Hydase®(PrimaPharm, Inc). In some instances, a hyluronidase is an ovinehyaluronidase, Vitrase® (ISTA Pharmaceuticals). In certain instances, ahyaluronidase described herein is a recombinant hyaluronidase. In someinstances, a hyaluronidase described herein is a humanized recombinanthyaluronidase. In some instances, a hyaluronidase described herein is apegylated hyaluronidase (e.g., PEGPH20 (Halozyme)). In certaininstances, the enzyme is obtained from a pathogen. In certain instances,the pathogen is Streptococcus and the enzyme is a hyaluronidase, and/ora streptokinase. In certain instances, the pathogen is Staphylococcusand the enzyme is a lipase, V8 protease, elastase, hyaluronidase, and/ora staphlokinase. In certain instances, the pathogen is Bacillusanthracis, or a Clostridium and the enzyme is a metalloproteinase. Incertain instances, the pathogen is Bacillus thermoproteolyticus and theenzyme is thermolysin. In certain instances, the pathogen is Candidaalbicans and the enzyme is candidapepsin.

Anaphylatoxin Modulators

In some embodiments, an anaphylatoxin modulator is administered to asubject in need thereof. In some embodiments, the anaphylatoxinmodulator is an antagonist of C5a. In some embodiments, the C5aantagonist is chemotaxis inhibitory protein of S. aureus (CHIPS), PMX53(AcF[OP-DCha-WR]), PMX205 (HC—[OPdChaWR]), PMX273 (AcF[OP-DPhe-WR]),PMX201 (AcF[OP-DCha-WCit]), PMX218 (HC—[OPdPheWR]), C089(NMePhe-Lys-Pro-dCha-X-dArg), L-156,602(D-Alanine,(RS,2R,5R,6R)-tetrahydro-R,2-dihydroxy-R,6-dimethyl-5-[(2S)-2-methylbutyl]-2H-pyran-2-acetyl-(3S)-3-hydroxy-L-leucyl-(3R)-hexahydro-3-pyridazinecarbonyl-N-hydroxy-L-alanylglycyl-(3S)-hexahydro-3-pyridazinecarbonyl-N-hydroxy-(7f2)-lactone,CAS #: 125228-51-5), C5aRAM, C5aRAD, or combinations thereof. In certaininstances, a C5a antagonist binds to a C5aR and thereby antagonizes thebinding of C5a. In certain instances, CHIPS binds to the C5a receptor(C5aR) on a macrophage thereby inhibiting the C5a induced chemotaxis ofa macrophage. In certain instances, C5aRAM and C5aRAD are derived fromthe modification of the C terminus of C5a.

In some embodiments, the antagonist of C5aR activation is an antisensepeptide. In some embodiments, the antisense peptide of C5a is PR226-MAP(LRTWSRRATRSTKTLKVV), PL37-MAP (RAARISLGPRCIKAFTE), or combinationsthereof. In certain instances, a C5a antagonist binds to a C5aR andthereby antagonizes the binding of C5a.

In some embodiments, an anaphylatoxin modulator is administered to asubject in need thereof. In some embodiments, the anaphylatoxinmodulator is an antagonist of C3a. In some embodiments, the C3aantagonist is SB-290157 (N(2)-[(2,2-diphenylethoxy)acetyl]-L-arginine).In certain instances, SB-290157 binds to the C3a receptor (C3aR) therebyblocking the binding of C3a.

Complement Activators

In some embodiments, a complement activator is administered to a subjectin need thereof. In some embodiments, the complement activator isGR-2II, a pectic arabinogalactan (e.g. AGIIa, and AGIIb-1), a pectin(e.g. AR-2IIa, AR-2IIb, AR-2IIc, and AR-2IId), CVF, or combinationsthereof. In certain instances, AR-2IIa, AR-2IIb, and AR-2IIc activatethe complement system via the classical pathway and not the alternativepathway.

Cobra Venom Factor (CVF) is a three-chain (α-chain, β-chain, andγ-chain) glycoprotein extracted from the reptile Naja sp. CVF is a humancomplement system activating protein. It is structurally homologous toC3b. In certain instances, CVF binds to Factor B which is then cleavedby Factor D. The resulting complex, CVFBb, functions as a C3 convertaseand a C5 convertase. At 7.5 hours CVFBb exhibits a longer half-life thanC3bBb (1.5 minutes). Further, CVFBb is resistant to disassembly byFactor H and CVF is resistant to inactivation by Factor I. As a result,CVFBb will continuously hydrolyze C3 and C5. The continuoushydrolyzation of C3 and C5 results in the depletion (or exhaustion) ofthe complement system within several hours. However, resynthesis of thecomponents of the complement system begins quickly and the entire systemis reconstituted with 5-10 days.

In certain instances, CVF is highly antigenic in vivo. As a result,several humanized analogs and/or derivatives of CVF have beenengineered. In certain instances, these derivatives exhibit similaractivity to natural CVF (e.g. 50-97% of the activity of natural CVF);however, they do not or have a reduced capability of activating animmune response in vivo. In certain analogs and/or derivatives, severalamino acids from the β-chain of the CVF polypeptide are removed. Infurther analogs and/or derivatives, the CVF polypeptide is conjugated toa human antibody (e.g. monoclonal antibodies against antigen on humanleukemia cells, human neuroblastoma cells, and human melanoma cells). Insome analogs and/or derivatives, a human C3 derivative and/or analog(e.g. recombinant C3, rC3, humanized CVF) is engineered such that thehuman C3 derivative and/or analog comprises a portion of a CVFpolypeptide sequence. In other analogs and/or derivatives, portions of ahuman C3 polypeptide (e.g. the α-chain; or portions of the carboxyterminal) are replaced with the corresponding portion of the CVFpolypeptide. In certain derivatives and/or analogs, the α-chain of thehuman C3 is replaced by the corresponding carboxy terminal amino acidsof the CVF polypeptide. In some embodiments, the CVF analog and/orderivative is HC3-1496, HC3-1496-2, HC3-1496-3, HC3-1496-4,HC3-1496/1617, HC3-1496-8, HC3-1496-9, HC3-1496-10, HC3-1496-11,HC3-1496-12, HC3-1496-13, HC3-1496-14, HC3-1496-15, HC3-1496-16,HC3-1496-17, or combinations thereof. For disclosures regarding theaforementioned CVF analogs and/or derivatives see PCT Pub. No. WO2005/003159; and PCT Pub. No. WO 2008/060634, which are hereinincorporated by reference for such disclosures. For additionaldisclosures regarding CVF derivatives and/or analogs see U.S. Pat. No.5,714,344, which is hereby incorporated by reference for suchdisclosures.

In some embodiments, CVF is administered to a subject in need thereof(e.g. a subject who will benefit from complement depletion). In someembodiments, a CVF derivative is administered to a subject in needthereof.

Complement Component 1 Modulators

In some embodiments, a complement component 1 (C1) modulator isadministered to a subject in need thereof. In some embodiments, thecomplement C1 modulator is a C1 inhibitor. In certain instances, the C1inhibitor prevents fluid-phase C1 activation. In certain instances,administration of C1 inhibitor prevents reperfusion injury. In someembodiments, dextran sulfate is administered to a subject in needthereof. In some embodiments, C1 inhibitor is administered before,after, or simultaneous with dextran sulfate. In certain instances,dextran sulfate potentiates C1 inhibitor.

In some embodiments, a complement component 1q receptor (C1 qR) isadministered to a subject in need thereof. In certain instances, C1qregulates the presentation of adhesion molecules on endothelial cells.In certain instances, a C1q receptor (e.g. cC1qR, C1qRp, and gC1qR)prevents complement-mediated lysis of C1q sensitized erythrocytes. Incertain instances, administration of C1 inhibitor prevents reperfusioninjury.

In some embodiments, an antagonist of C1q binding is administered to asubject in need thereof. In some embodiments, the antagonist of C1qbinding is C1q inhibitor, decorin, CSPG (chondroitin sulfateproteoglycan), CBP2 (complement binding peptide 2), or combinationsthereof. In certain instances, CSPG partially or fully inhibits thebinding of C1q to C1s and C1r, thereby interfering with the formation ofthe enzyme C₁. In certain instances, CBP2 interferes with the binding ofC1q to an antigen or antigen-bound antibody.

Complement Receptor 1

In some embodiments, a complement receptor 1 (CR1) is administered to asubject in need thereof. By binding to C3b and C4b CR1 promotesphagocytosis and clearance of antigen-antibody complexes. Further, itinhibits both the classic and alternative pathways. In certaininstances, CR1 acts as a decay-accelerator for both C3 and C5.Additionally, in certain instances, CR1 acts as a Factor I cofactor.

In some embodiments, a soluble CR1 (sCR1) is administered to a subjectin need thereof. Soluble CR1 lacks the transmembrane and cytoplasmicdomains of CR1. In certain instances, sCR1 decrease the amount of MACproduced by the complement system. In certain instances, sCR1ameliorates ischemic/reperfusion injuries. In certain instances, sCR1reduces cellular and tissue injuries in animal models with acute orchronic inflammatory disorders. In some embodiments, the sCR1 is APT070(Mirococept), TP10 (Avant Immunotherapeutics), TP20 (AvantImmunotherapeutics), or combinations thereof.

In some embodiments, a soluble CR1 (sCR1) lacking the long homologousrepeat A (LHR-A) domain (sCR1[desLHR-A]) is administered to a subject inneed thereof. sCR1[desLHR-A] lacks the transmembrane and cytoplasmicdomains of CR1 and the C4b binding domain. In certain instances,sCR1[desLHR-A] inhibits the alternative pathway but exhibits adiminished ability to inhibit the classical pathway as compared to sCR1.

In some embodiments, a soluble CR1 (sCR1) bound by SLe^(x) moieties isadministered to a subject in need thereof. SLe^(x) is a carbohydrateligand for selectins that, in certain instances, inhibits E-selectin andP-selectin mediated neutrophil adhesion. In certain instances,sCR1-SLe^(x) inhibits complement activation and inhibits the recruitmentof neutrophils to the site of inflammation.

Complement Receptor 1-Related Gene/Protein

In some embodiments, a complement receptor 1-related gene/protein y(Crry) is administered to a subject in need thereof. In someembodiments, a recombinant Crry (Crry-Ig) is administered to a subjectin need thereof. Crry inhibits both the classic and alternativepathways. In certain instances, Crry acts as a decay-accelerator forboth C3 and C5. Additionally, in certain instances, Crry acts as aFactor I cofactor.

Complement Component 3 Convertase Modulators

In some embodiments, a modulator of C3 convertase is administered to asubject in need thereof. In some embodiments, the C3 convertasemodulator is a fucan. In some embodiments, a fucan is extracted frombrown seaweed (e.g. Phaeophyceae, Ascophyllum nodosum, and Eckloniakurome). In certain instances, a fucan partially or fully suppresses theclassical pathway. In certain instances, a fucan partially or fullysuppresses the alternative pathway. In some embodiments, the fucan isBS8. In certain instances, BS8 partially or fully inhibited formation ofC4bC2a by interfering with C1 activation. In certain instances, BS8partially or fully inhibited formation of C4bC2a by interfering C4cleavage. In certain instances, BS8, partially or fully inhibits C3Bb byinterfering with the binding of Factor B to C3b and by interfering withthe binding of properdin.

In some embodiments, a modulator of C3 convertase is administered to asubject in need thereof. In some embodiments, the C3 convertasemodulator is complestatin. In certain instances, complestatin interfereswith the binding of C4b and C2b, and thus antagonizes the formation ofthe classical C3 convertase (C4bC2b).

In some embodiments, a modulator of C3 convertase is administered to asubject in need thereof. In some embodiments, the C3 convertasemodulator is extracellular complement-binding protein (Ecb). In certaininstances, Ecb is isolated from S. aureus. In certain instances, itmodulates C3b containing molecules (e.g. the alternative C3 convertaseC3bB3, and the C5 convertases C4bC2aC3b and C3bBbC3b) by blocking theability of C3b containing molecules to cleave their substrates (e.g. C3and C5).

In some embodiments, a modulator of C3 convertase is administered to asubject in need thereof. In some embodiments, the C3 convertasemodulator is extracellular fibrinogen-binding protein (Efb). In certaininstances, Efb is isolated from S. aureus. In certain instances, Efbmodulates C3b containing molecules (e.g. the alternative C3 convertaseC3bB3) by blocking the ability of C3bBb to cleave C3.

In some embodiments, a modulator of C3 convertase is administered to asubject in need thereof. In some embodiments, the C3 convertasemodulator is compstatin. In certain instances, compstatin antagonizes C3convertases by binding to C3 and partially or fully inhibiting theability for a C3 convertase to bind to and cleave C3.

In some embodiments, a modulator of C3 convertase is administered to asubject in need thereof. In some embodiments, the C3 convertasemodulator is rosmarinic acid. In certain instances, rosmarinic acidreacts with the activated thioester of metastable C3b. In certaininstances, the reaction of rosmarinic acid and the activated thioesterof metastable C3b results in covalent attachment of rosmarinic acid to aC3 convertase. In certain instances, the covalent attachment ofrosmarinic acid to a C3 convertase prevents the binding of a C3convertase to a host cell or pathogen.

In some embodiments, a modulator of C3 convertase is administered to asubject in need thereof. In some embodiments, the C3 convertasemodulator is CRIT. In some embodiments, the C3 convertase modulator is apeptide sequence comprising the C-terminal 11-amino-acid of the firstCRIT-extracellular domain (CRIT-H17). In certain instances, CRITinhibits the formation of C3 convertase. In certain instances, CRITbinds to C2, thus inhibiting C4b from binding to C2 and forming C3convertase.

In some embodiments, a modulator of C3 convertase is administered to asubject in need thereof. In some embodiments, the C3 convertasemodulator is glycyrrhetinic acid. In certain instances, glycyrrhetinicacid modulates C2 and thus modulates the formation of the classicalpathway C3 convertase.

Complement Component 5 Convertase Modulators

In some embodiments, a modulator of C5 convertase is administered to asubject in need thereof. In some embodiments, the C5 convertasemodulator is an anti-complement component 5 (C5) murine monoclonal. Incertain instances, an anti-C5 mAb partially or fully inhibits thecleavage of C5 by C5 convertase. In certain instances, an anti-C5 mABinhibits the formation of C5a. In certain instances, an anti-C5 mAbpartially or fully inhibits the formation of C5b and thus the formationof a MAC. In certain instances, an anti-C5 mAB does not inhibit thecleavage of a C3. In some embodiments, an anti-C5 mAB is derived fromthe variable region of the N19/8 mAb. In certain instances,administration of an anti-C5 mAB ameliorates an autoimmune disease. Incertain instances, an anti-C5 mAB partially or fully inhibits CD11bup-regulation. In certain instances, decreases the number of P-selectinpresenting platelets. In certain instances, an anti-C5 mAB reduces theformation of leukocyte-platelet aggregates. In some embodiments, the C5antibody is pexelizumab.

In some embodiments, an anti-C5 murine single-chain antibody isadministered to a subject in need thereof. In some embodiments, ananti-C5 murine single-chain antibody is derived from the variable regionof the N19/8 mAb. In certain instances, an anti-C5 murine single-chainantibody is inhibits the cleavage of C5 and the production of C5a. Incertain instances, an anti-C5 murine single-chain antibody is partiallyor fully inhibits C5b-9-mediated hemolysis of erythrocytes. In someembodiments, an anti-C5 humanized single-chain antibody (e.g. 5G1.1-SC)is administered to a subject in need thereof.

In some embodiments, a modulator of C5 convertase is administered to asubject in need thereof. In some embodiments, the C5 convertasemodulator is K76(6,7-diformyl-3′,4′,4a′,5′,6′,7′,8′,8a′-octahydro-4,6′,7′-trihydroxy-2′,5′,5′,8a′-tetramethylspiro[1′(2′H)-naphthalene-2(3M)-benzofuran]), or a derivative thereof(e.g. TKIXc, and K76 COOH). In certain instances, K76 antagonizes C5convertase by interfering with the ability of C5 convertase to bind toand/or cleave C5.

In some embodiments, a modulator of C5 convertase is administered to asubject in need thereof. In some embodiments, the C5 convertasemodulator is a staphylococcal complement inhibitor (e.g. SCIN, SCIN-B,and SCIN-C). In certain instances, a staphylococcal complement inhibitoris isolated from S. aureus. In certain instances, an SCIN binds to andstabilizes a C3 convertase (e.g. C4bC2a and C3bBb). In certaininstances, the binding of an SCIN prevents the binding of a C3b subunitto the complex; thus, preventing the formation of a C5 convertase from aC3 convertase.

CD55

In some embodiments, a CD55 is administered to a subject in needthereof. CD55, also known as Decay Accelerating Factor (DAF), binds bothC4b and C3b. In certain instances, the binding of CD55 to C4bdisassociates the C3 convertase of the classical pathway and thus alsoinhibits the formation of the classical C5 convertase. In certaininstances, the binding of CD55 to C3b disassociates the C3 and C5convertases of the alternative pathway. In some embodiments, a CD55protein is a soluble protein (sCD55). In some embodiments, sCD55 isadministered to a subject in need thereof.

CD59

In some embodiments, a CD59 protein is administered to a subject in needthereof. In certain instances, CD59 inhibits the formation of a MAC bybinding to C8 and C9 and thereby preventing their binding to the C5bC6C7complex. In some embodiments, a soluble CD59 (sCD59) protein isadministered to a subject in need thereof.

CD55/CD59 Fusion Proteins

In some embodiments, a CD59/CD55 fusion protein is administered to asubject in need thereof. In certain instances, the CD59 subunit inhibitsthe formation of a MAC by binding to C8 and C9 and thereby preventingtheir binding to the C5bC6C7 complex. In certain instances, a CD59/CD55fusion protein prevents the formation of a MAC, and prevents theformation of or inhibits the activity of a C5 convertase. In certaininstances, the CD55 subunit binds to C4b thereby disassociating the C3convertase of the classical pathway and inhibiting the formation of theclassical C5 convertase. In certain instances, the CD55 subunit binds toC3b thereby disassociating the C5 convertase of the alternative pathway.

CD55/MCP Fusion Proteins

In some embodiments, a CD55/MCP fusion protein is administered to asubject in need thereof. In certain instances, the CD55 subunit binds toC4b thereby disassociating the C3 convertase of the classical pathwayand inhibiting the formation of the classical C5 convertase. In certaininstances, the CD55 subunit binds to C3b thereby disassociating the C5convertase of the alternative pathway. In certain instances, the MCP(Membrane Cofactor Protein, or CD46) subunit is a co-factor of Factor I.In certain instances, the MCP subunit activates Factor I leading to theinactivation of a C3 convertase of the classical pathway and/or a C3convertase of the alternative pathway. In some embodiments, the CD55/MCPfusion protein is a soluble protein sCD55/MCP (Complement ActivationBlocker-2, CAB-2). In certain instances, CAB-2 exhibits greaterantagonism of convertases (e.g. C3 and C5) as compared to either CD55administered alone, MCP administer alone, or CD55 and MCP administeredin combination. In certain instances, CAB-2 inhibits complementactivation in vivo.

Factor D Modulators

In some embodiments, a Factor D modulator is administered to a subjectin need thereof. In some embodiments, the Factor D modulator is a FactorD antagonist. In some embodiments, the Factor D antagonist is BCX-1470(2-amidino-6-(2-thiophene carboxy)benzothiophene methanesulfonate);FUT-175 (6-amidino-2-naphthyl p-guanidinobenzoate dimethane-sulphonate);or combinations thereof. In certain instances, Factor D antagonistsinhibit the formation of the alternative pathway fluid phase C3convertase by antagonizing Factor D's ability to bind to and cleaveFactor B.

Factor I and Factor I Co-Factors

In some embodiments, a Factor I protease and a co-factor thereof areadministered to a subject in need thereof. In certain instances, FactorI when bound to a co-factor, cleaves C3b and/or C4b; thus, inactivatingthem. The inactivation of C4b (iC4b) inhibits the activity of a C3convertase of the classical pathway and thus also inhibits the formationof the classical C5 convertase. Further, the inactivation of C3b (iC3b)inhibits the activity of a C3 and C5 convertases of the alternativepathway.

In some embodiments, a Membrane Cofactor Protein (MCP OR CD46) isadministered to a subject in need thereof. MCP is a co-factor of FactorI. In some embodiments, MCP is administered to a subject in need thereofin soluble form (sMCP). In some embodiments, sMCP and/or MCP isadministered before, after, or simultaneously with Factor I. In someembodiments, sMCP and/or MCP is administered with CD55. In certaininstances, administration of sMCP inhibits complement-mediatedinflammation. In certain instances, administration of MCP activatesFactor I leading to the inactivation of a C3 convertase of the classicalpathway and/or a C3 convertase of the alternative pathway. In certaininstances, administration of MCP activates Factor I leading to adecrease in the production of C5 convertase the classical pathway and/orinactivation of a C5 convertase of the alternative pathway.

Heparin

In some embodiments, heparin or a derivative thereof (e.g. LU 51198) isadministered to a subject in need thereof. In certain instances, heparininteracts with C₁, C2, C3, C4, C5, C6, C7, C8, C9, C11NH, factor I,factor H, factor B and factor P. In certain instances, heparin partiallyor fully inhibits the formation of the alternative pathway C3 convertase(C3Bb) and the classical pathway C3 convertase (C4bC2a).

MAC Modulators

In some embodiments, an MAC modulator is administered to a subject inneed thereof. In some embodiments, the MAC modulator is clusterin,vitronectin. In certain instances, clusterin partially or fully inhibitsthe formation of fluid-phase MAC. In certain instances, vitronectinpartially or fully inhibits the formation of fluid-phase MAC.

MIF Modulators

In some embodiments, an MIF modulator is administered to a subject inneed thereof. In some embodiments, the MIF modulator is an inhibitorand/or an antagonist of MIF. In some embodiments, an MIF modulatordecreases inflammation. In some embodiments, an MIF modulatordownregulates the production of a cytokine (e.g. TNF-α and IL-8). Insome embodiments, an MIF modulator ameliorates the symptoms of OME. Insome embodiments, the inhibitor and/or antagonist of MIF is an anti-MIFantibody. In certain instances, the administration of an anti-MIFantibody decreases the production of TNF-α and IL-8. In someembodiments, the inhibitor and/or antagonist of MIF is metformin. Incertain instances, the administration of metformin decreases plasma MIFconcentrations. In some embodiments, the inhibitor and/or antagonist ofMIF is ISO-1 ((S,R)-3(4-hydroxyphenyl)-4,5-dihydro-5-isoxazole aceticacid methyl ester). In certain instances, the administration of an ISO-1decreases the production of TNF-α and IL-8. In some embodiments, theinhibitor and/or antagonist of MIF is2-[(4-hydroxybenzylidene)amino]-3(1H-indol-3-yl)propionic acid methylester. In some embodiments, the inhibitor and/or antagonist of MIF isNAPQI (N-acetyl-p-benzoquinone imine). In some embodiments, theinhibitor and/or antagonist of MIF is AVP-28225 (AvanirPharmaceuticals).

Properdin Antibodies

In some embodiments, an anti-properdin antibody is administered to asubject in need thereof. In some embodiments, the anti-properdinantibody is a monoclonal antibody. In certain instances, ananti-properdin inhibits the stabilization of the alternative pathwayunstable C3 convertase (C3Bb). In certain instances, an anti-properdinantibody inhibits the formation of the alternative pathway C5 convertase(C3BbC3). In certain instances, an anti-properdin antibody inhibits theformation of MAC.

Miscellaneous Complement Modulators

In some embodiments, the complement modulator is glycyrrhizin,glycyrrhetinic acid, or combinations thereof. In certain instances,glycyrrhetinic acid modulates C2 and thus modulates the formation of theclassical pathway C3 convertase.

Concentration of Active Agent

In some embodiments, the concentration of an otic structure modulatingagent or innate immune system modulating agent in a pharmaceuticalcomposition or device described herein is about 1% by weight of thecomposition. In some embodiments, the concentration of an otic structuremodulating agent or innate immune system modulating agent in apharmaceutical composition or device described herein is about 2% byweight of the composition. In some embodiments, the concentration of anotic structure modulating agent or innate immune system modulating agentin a pharmaceutical composition or device described herein is about 3%by weight of the composition. In some embodiments, the concentration ofan otic structure modulating agent or innate immune system modulatingagent in a pharmaceutical composition or device described herein isabout 4% by weight of the composition. In some embodiments, theconcentration of an otic structure modulating agent or innate immunesystem modulating agent in a pharmaceutical composition or devicedescribed herein is about 5% by weight of the composition. In someembodiments, the concentration of an otic structure modulating agent orinnate immune system modulating agent in a pharmaceutical composition ordevice described herein is about 10% by weight of the composition. Insome embodiments, the concentration of an otic structure modulatingagent or innate immune system modulating agent in a pharmaceuticalcomposition or device described herein is about 15% by weight of thecomposition. In some embodiments, the concentration of an otic structuremodulating agent or innate immune system modulating agent in apharmaceutical composition or device described herein is about 20% byweight of the composition. In some embodiments, the concentration of anotic structure modulating agent or innate immune system modulating agentin a pharmaceutical composition or device described herein is about 25%by weight of the composition. In some embodiments, the concentration ofan otic structure modulating agent or innate immune system modulatingagent in a pharmaceutical composition or device described herein isabout 30% by weight of the composition. In some embodiments, theconcentration of an otic structure modulating agent or innate immunesystem modulating agent in a pharmaceutical composition or devicedescribed herein is about 40% by weight of the composition. In someembodiments, the concentration of an otic structure modulating agent orinnate immune system modulating agent in a pharmaceutical composition ordevice described herein is about 50% by weight of the composition. Insome embodiments, the concentration of an otic structure modulatingagent or innate immune system modulating agent in a pharmaceuticalcomposition or device described herein is about 60% by weight of thecomposition. In some embodiments, the concentration of an otic structuremodulating agent or innate immune system modulating agent in apharmaceutical composition or device described herein is about 70% byweight of the composition. In some embodiments, the concentration of anotic structure modulating agent or innate immune system modulating agentin a pharmaceutical composition or device described herein is about 80%by weight of the composition. In some embodiments, the concentration ofan otic structure modulating agent or innate immune system modulatingagent in a pharmaceutical composition or device described herein isabout 90% by weight of the composition.

In some embodiments, the compositions described herein have aconcentration of active pharmaceutical ingredient, or pharmaceuticallyacceptable prodrug or salt thereof, between about 0.1 to about 70 mg/mL,between about 0.5 mg/mL to about 70 mg/mL, between about 0.5 mg/mL toabout 50 mg/mL, between about 0.5 mg/mL to about 20 mg/mL, between about1 mg to about 70 mg/mL, between about 1 mg to about 50 mg/mL, betweenabout 1 mg/mL and about 20 mg/mL, between about 1 mg/mL to about 10mg/mL, or between about 1 mg/mL to about 5 mg/mL, of the active agent,or pharmaceutically acceptable prodrug or salt thereof, by volume of thecomposition.

Combination Therapy

In some embodiments, the formulations disclosed herein are administeredin combination with an additional otic active agent. In someembodiments, the formulations disclosed herein are administered before,during, or after administration of an additional active agent. In someembodiments, the additional otic active agent is an antihistamine, GABAreceptor modulator, a neurotransmitter reuptake inhibitor, ananticholinergic, a local anesthetic, an inhibitor of the MAPK/JNKcascade, a calcium channel blocker, a sodium channel blocker, an agonistof HO, an antagonist of a caspase, an antagonist of a calpain, a sirtuinagonist, an Src antagonist, a carbamate, a gamma-secretase inhibitor, aglutamate receptor modulator, a growth factor, an ototoxic agent, athyroid hormone receptor modulator, a TRPV modulator, an antiemeticagent, an antimicrobial agent, an antiseptic agent, an antioxidant, aTNF antagonist, a TNF-α converting enzyme inhibitor, an IKK inhibitor, acalcineurin inhibitor, a toll-like receptor inhibitor, an interleukininhibitor, a NOS inhibitor, a platelet activating factor antagonist, orcombinations thereof.

In certain instances, the otic structure degrading agents andcompositions disclosed herein facilitate the penetration of an oticactive agent into the middle and/or inner ear by degrading oticstructures (e.g. cells, lipid matrix, extracellular matrix, desmosome).In certain instances, a smaller dose of the additional active agent isadministered to a subject in need thereof when the otic active agent isadministered with the otic structure degrading agents and compositionsdisclosed herein. In certain instances, an improved pharmacokineticprofile for the otic active agent is obtained when the otic active agentis administered with the otic structure degrading agents andcompositions disclosed herein.

Anticholinergics

Anticholinergics are optionally used with the formulations disclosedherein. Anticholinergics include glycopyrrolate, homatropine,scopolamine or atropine.

Anti-Emetic Agents

Anti-Emetic agents are optionally used in the formulations disclosedherein. Exemplary anti-emetic agents include promethazine,prochlorperazine, trimethobenzamide, and triethylperazine. Otheranti-emetic agents include 5HT3 antagonists such as dolasetron,granisetron, ondansetron, tropisetron, and palonosetron; andneuroleptics such as droperidol. Further anti-emetic agents includeantihistamines, such as meclizine; phenothiazines such as perphenazine,and thiethyl perazine; dopamine antagonists, including domperidone,properidol, haloperidol, chlorpromazine, promethazine, prochlorperazine,metoclopramide and combinations thereof, cannabinoids, includingdronabinol, nabilone, sativex, and combinations thereof,anticholinergics, including scopolamine; and steroids, includingdexamethasone; trimethobenzamine, emetrol, propofol, muscimol, andcombinations thereof.

Antihistamines

Antihistamines are optionally used in the formulations disclosed herein.Antihistamines include, and are not limited to, meclizine,diphenhydramine, dimenhydrinate, loratadine, quetiapine, mepyramine,piperoxan, antazoline, carbinoxamine, doxylamine, clemastine,pheniramine, chlorphenamine, chlorpheniramine, dexchlorpheniramine,brompheniramine, triprolidine, cyclizine, chlorcyclizine, hydroxyzine,promethazine, alimemazine, trimeprazine, cyproheptadine, azatadine,ketotifen, oxatomide, betahistine dihydrochloride.

Antimicrobial Agents

Antimicrobial agents are also contemplated as useful with theformulations disclosed herein. Some examples of antimicrobial agentsinclude agents that act to inhibit or eradicate microbes, includingbacteria, fungi or parasites. Specific antimicrobial agents may be usedto combat specific microbes. Accordingly, a skilled practitioner wouldknow which antimicrobial agent would be relevant or useful depending onthe microbe identified, or the symptoms displayed. Antimicrobial agentsinclude antibiotics, antiviral agents, antifungal agents, andantiparasitic agents.

Antibiotics may also include amikacin, gentamicin, kanamycin, neomycin,netilmicin, streptomycin, tobramycin, paromomycin, geldanmycin,herbimycin, loracarbef, ertapenem, doripenem, imipenem, cilastatin,meropenem, cefadroxil, cefazolin, cefalotin, cefalexin, cefaclor,cefamandole, cefoxitin, defprozil, cefuroxime, cefixime, cefdinir,cefditoren, cefoperazone, cefotaxime, cefpodoxime, ceftazidime,ceftibuten, ceftizoxime, ceftriaxone, cefepime, ceftobiprole,teicoplanin, vancomycin, azithromycin, clarithromycin, dirithromycin,erythromycin, roxithromycin, troleandomycin, telithromycin,spectinomycin, aztreonam, amoxicillin, ampicillin, azlocillin,carbenicillin, cloxacillin, dicloxacillin, flucloxacillin, mezlocillin,meticillin, nafcillin, oxacillin, penicillin, piperacillin, ticarcillan,bacitracin, colistin, polymyxin B, ciprofloxacin, enoxacin,gatifloxacin, levofloxacin, lomefloxacin, moxifloxacin, norfloxacin,ofloxacin, trovfloxacin, mafenide, prontosil, sulfacetamide,sulfamethizole, sulfanimilimde, sulfsalazine, sulfsioxazole,trimethoprim, demeclocycline, doxycycline, minocycline, oxtetracycline,tetracycline, arsphenamine, chloramphenicol, clindamycin, lincomycin,ethambutol, fosfomycin, fusidic acid, furazolidone, isoniazid,linezolid, metronidazole, mupirocin, nitrofurantoin, platensimycin,pyrazinamide, quinuspristin/dalfopristin, rifampin, tinidazole, andcombinations thereof.

Antiviral agents may include acyclovir, famciclovir and valacyclovir.Other antiviral agents include abacavir, aciclovir, adfovir, amantadine,amprenavir, arbidol, atazanavir, artipla, brivudine, cidofovir,combivir, edoxudine, efavirenz, emtricitabine, enfuvirtide, entecavir,fomvirsen, fosamprenavir, foscarnet, fosfonet, ganciclovir, gardasil,ibacitabine, immunovir, idoxuridine, imiquimod, indinavir, inosine,integrase inhibitors, interferons, including interferon type III,interferon type II, interferon type I, lamivudine, lopinavir, loviride,MK-0518, maraviroc, moroxydine, nelfinavir, nevirapine, nexavir,nucleoside analogues, oseltamivir, penciclovir, peramivir, pleconaril,podophyllotoxin, protease inhibitors, reverse transcriptase inhibitors,ribavirin, rimantadine, ritonavir, saquinavir, stavudine, tenofovir,tenofovir disoproxil, tipranavir, trifluridine, trizivir, tromantadine,truvada, valganciclovir, vicriviroc, vidarabine, viramidine,zalcitabine, zanamivir, zidovudine, and combinations thereof.

Antifungal agents may include ammolfine, utenafine, naftifine,terbinafine, flucytosine, fluconazole, itraconazole, ketoconazole,posaconazole, ravuconazole, voriconazole, clotrimazole, econazole,miconazole, oxiconazole, sulconazole, terconazole, tioconazole,nikkomycin Z, caspofungin, micafungin, anidulafungin, amphotericin B,liposomal nystastin, pimaricin, griseofulvin, ciclopirox olamine,haloprogin, tolnaftate, undecylenate, and combinations thereof.Antiparasitic agents may include amitraz, amoscanate, avermectin,carbadox, diethylcarbamizine, dimetridazole, diminazene, ivermectin,macrofilaricide, malathion, mitaban, oxamniquine, permethrin,praziquantel, prantel pamoate, selamectin, sodium stibogluconate,thiabendazole, and combinations thereof.

Antioxidants

Antioxidants are also contemplated as being useful with the formulationsdisclosed herein are agents that modulate the degeneration of neuronsand/or hair cells of the auris. Accordingly, some embodimentsincorporate the use of antioxidants. In some embodiments, theantioxidant is vitamin C, N-acetylcysteine, vitamin E, Ebselen(2-phenyl-1,2-benzisoselenazol-3(2H)-one (also called PZ 51 or DR3305),L-methionine, Idebenone(2-(10-hydroxydecyl)-5,6-dimethoxy-3-methyl-cyclohexa-2,5-diene-1,4-dione).

Anti-Septic Agents

Anti-septic agents are also contemplated as useful with the formulationsdisclosed herein. Anti-septic agents include, but are not limited to,acetic acid, boric acid, gentian violet, hydrogen peroxide, carbamideperoxide, chlorhexidine, saline, mercurochrome, povidone iodine,polyhyroxine iodine, cresylate and aluminum acetate, and mixturesthereof.

Calcium Channel Blockers

Calcium channel blockers are optionally used with the formulationsdisclosed herein. Exemplary calcium channel blockers include verapamil,nimodipine, diltiazem, omega-conotoxin, GVIA, amlodipine, felodipine,lacidipine, mibefradil, NPPB (5-Nitro-2-(3-phenylpropylamino)benzoicAcid), flunarizine, or combinations thereof.

Caspase Antagonists

Caspase antagonists are optionally used in the formulations disclosedherein. Caspase antagonists include, but are not limited to, z-VAD-FMK(Benzyloxycarbonyl-Val-Ala-Asp(OMe)-fluoromethylketone); z-LEHD-FMK(benzyloxycarbonyl-Leu-Glu(OMe)-His-Asp(OMe)-fluoromethylketone);B-D-FMK (boc-aspartyl(Ome)-fluoromethylketone);Ac-LEHD-CHO(N-acetyl-Leu-Glu-His-Asp-CHO);Ac-IETD-CHO(N-acetyl-Ile-Glu-Thr-Asp-CHO); z-IETD-FMK(benzyloxycarbonyl-Ile-Glu(OMe)-Thr-Asp(OMe)-fluoromethylketone);FAM-LEHD-FMK (benzyloxycarbonyl Leu-Glu-His-Asp-fluoromethyl ketone);FAM-LETD-FMK (benzyloxycarbonyl Leu-Glu-Thr-Asp-fluoromethyl ketone);Q-VD-OPH (Quinoline-Val-Asp-CH₂—O—Ph); or combinations thereof.

Calcineurin Inhibitors

Calcineurin inhibitors are optionally used in the formulations disclosedherein. Some examples of calcineurin inhibitors include cyclosporine,tacrolimus and pimecrolimus.

Calpain Antagonists

Calpain antagonists are optionally used with the formulations disclosedherein. Calpain antagonists include, but are not limited to, leupeptine;PD-150606 (3-(4-Iodophenyl)-2-mercapto-(Z)-2-propenoic acid); MDL-28170(Z-Val-Phe-CHO); calpeptin; acetyl-calpastatin; MG 132(N-[(phenylmethoxy)carbonyl]-L-leucyl-N-[(1S)-1-formyl-3-methylbutyl]-L-leucinamide);MYODUR; BN 82270 (Ipsen); BN 2204 (Ipsen); or combinations thereof.

Carbamates

Carbamates are optionally used in the formulations disclosed herein.Examples of carbamates include 2-phenyl-1,2-ethanediol monocarbomatesand dicarbamates, derivatives thereof, and/or combinations thereof.

GABA Receptor Modulators

GABA Receptor Modulators are optionally used with the formulationsdisclosed herein. By way of example, GABA Receptor Modulators includealprazolam, bromazepam, brotizolam, chlordiazepoxide, clonazepam,clorazepate, diazepam, estazolam, flunitrazepam, flurazepam, loprazolam,lorazepam, lormetazepam, idazolam, nimetazepam, nitrazepam, oxazepam,prazepam, temazepam, triazolam, furosemide, bumetanide, ethacrynic acid,gabapentin, pregabalin, muscimol, or baclofen.

Gamma-Secretase Inhibitors

Gamma-Secretase Inhibitors are optionally used in the formulationsdisclosed herein. Gamma-Secretase Inhibitors include, but are notlimited to, LY450139 (hydroxylvaleryl monobenzocaprolactam), L685458(1S-benzyl-4R[1-[1-S-carbamoyl-2-phenethylcarbamoyl)-1S-3-methylbutylcarbamoyl]-2R-hydroxy-5-phenylpentyl}carbamicacid tert-butyl ester); LY411575(N²-[(2S)-2-(3,5-difluorophenyl)-2-hydroxyethanoyl]-N¹[(7S)-5-methyl-6-oxo-6,7-dihydro-5H-dibenzo[bid]azepin-7yl]-L-alaninamide),MK-0752 (Merck), tarenflurbil, and/or BMS-299897(2-[(1R)-1-[[(4-chlorophenyl)sulfony](2,5-difluorophenyl)amino]ethyl]-5-fluorobenzenepropanoicacid).

Glutamate-Receptor Modulators

Glutamate receptor modulating agents are optionally used with theformulations disclosed herein. In some embodiments, glutamate receptormodulating agents include CNQX (6-cyano-7-nitroquinoxaline-2,3-dione);NBQX (2,3-dihydroxy-6-nitro-7-sulfamoyl-benzo[f]quinoxaline-2,3-dione);DNQX (6,7-dinitroquinoxaline-2,3-dione); kynurenic acid;2,3-dihydroxy-6-nitro-7-sulfamoylbenzo-[f]quinoxaline;1-aminoadamantane, dextromethorphan, dextrorphan, ibogaine, ketamine,nitrous oxide, phencyclidine, riluzole, tiletamine, memantine,dizocilpine, aptiganel, remacimide, 7-chlorokynurenate, DCKA(5,7-dichlorokynurenic acid), kynurenic acid,1-aminocyclopropanecarboxylic acid (ACPC), AP7(2-amino-7-phosphonoheptanoic acid), APV(R-2-amino-5-phosphonopentanoate), CPPene(3-[(R)-2-carboxypiperazin-4-yl]-prop-2-enyl-1-phosphonic acid);(+)-(1S,2S)-1-(4-hydroxy-phenyl)-2-(4-hydroxy-4-phenylpiperidino)-1-pro-panol;(1S,2S)-1-(4-hydroxy-3-methoxyphenyl)-2-(4-hydroxy-4-phenylpiperi-dino)-1-propanol;(3R,4S)-3-(4-(4-fluorophenyl)-4-hydroxypiperidin-1-yl-)-chroman-4,7-diol;(1R*,2R*)-1-(4-hydroxy-3-methylphenyl)-2-(4-(4-fluoro-phenyl)-4-hydroxypiperidin-1-yl)-propan-1-ol-mesylate;LY389795 ((−)-2-thia-4-aminobicyclo-hexane-4,6-dicarboxylate); LY379268((−)-2-oxa-4-aminobicyclo-hexane-4,6-dicarboxylate); LY354740((+)-2-aminobicyclo-hexane-2,6dicarboxylate); DCG-IV((2S,2′R,3′R)-2-(2′,3′-dicarboxycyclopropyl)glycine); 2R,4R-APDC(2R,4R-4-aminopyrrolidine-2,4-dicarboxylate), (S)-3C4HPG((S)-3-carboxy-4-hydroxyphenylglycine); (S)-4C3HPG((S)-4-carboxy-3-hydroxyphenylglycine); L-CCG-1((2S,1′S,2′S)-2-(carboxycyclopropyl)glycine); ACPT-1((1S,3R,4S)-1-aminocyclopentane-1,3,4-tricarboxylic acid); L-AP4(L-(+)-2-Amino-4-phosphonobutyric acid); (S)-3,4-DCPG((S)-3,4-dicarboxyphenylglycine); (RS)-3,4-DCPG((RS)-3,4-dicarboxyphenylglycine); (RS)-4-phosphonophenylglycine((RS)PPG); AMN082 (N′-bis(diphenylmethyl)-1,2-ethanediaminedihydrochloride); DCG-IV((2S,2′R,3′R)-2-(2′,3′-dicarboxycyclopropyl)glycine);3,5-Dimethylpyrrole-2,4-dicarboxylic acid 2-propyl ester4-(1,2,2-trimethyl-propyl) ester (3,5-dimethyl PPP);3,3′-difluorobenzaldazine (DFB), 3,3′-dimlethoxybenzaldazine (DMeOB),3,3′-dichlorobenzaldazine (DCB) and other allosteric modulators ofmGluR₅ disclosed in Mol. Pharmacol. 2003, 64, 731-740;(E)-6-methyl-2-(phenyldiazenyl)pyridin-3-ol (SIB 1757);(E)-2-methyl-6-styrylpyridine (SIB 1893);2-methyl-6-(phenylethynyl)pyridine (MPEP),2-methyl-4-((6-methylpyridin-2-yl)ethynyl)thiazole (MTEP);7-(Hydroxyimino)cyclopropa[b]chromen-1-carboxylate ethyl ester(CPCCOEt),N-cyclohexyl-3-methylbenzo[d]thiazolo[3,2-a]imidazole-2-carboxamide(YM-298198), tricyclo[3.3.3.1]nonanyl quinoxaline-2-carboxamide (NPS2390); 6-methoxy-N-(4-methoxyphenyl)quinazolin-4-amine (LY 456239);mGluR1 antagonists disclosed in WO2004/058754 and WO2005/009987;2-(4-(2,3-dihydro-1H-inden-2-ylamino)-5,6,7,8-tetrahydroquinazolin-2-ylthio)ethanol;3-(5-(pyridin-2-yl)-2H-tetrazol-2-yl)benzonitrile,2-(2-methoxy-4-(4-(pyridin-2-yl)oxazol-2-yl)phenyl)acetonitrile;2-(4-(benzo[d]oxazol-2-yl)-2-methoxyphenyl)acetonitrile;6-(3-methoxy-4-(pyridin-2-yl)phenyl)imidazo[2,1-b]thiazole;(S)-(4-fluorophenyl)(3-(3-(4-fluorophenyl)-1,2,4-oxadiazol-5-yl)piperidin-1-yl)methanone(ADX47273) and/or combinations thereof.

Growth Factors

Growth factors are optionally used in the formulations disclosed herein.Exemplary growth factors include brain-derived neurotrophic factor(BDNF), ciliary neurotrophic factor (CNTF), glial cell-line derivedneurotrophic factor (GDNF), neurotrophin-3, neurotrophin-4, and/orcombinations thereof. In some embodiments, the growth factor is afibroblast growth factor (FGF), an insulin-like growth factor (IGF), anepidermal growth factor (EGF), a platlet-derived growth factor (PGF)and/or agonists thereof.

HO-1 Agonists

Agoniosts of HO-1 are optionally used with the formulations disclosedherein. Agonists of HO-1 include, but are not limited to, piperine,hemin, and/or brazilin.

IKK Inhibitors

IKK inhibitors are optionally used in the formulations disclosed herein.Examples of IKK inhibitors include SPC-839, PS-1145, BMS-345541, andSC-514.

Interleukin Inhibitors

Interleukins inhibitors are optionally used with the formulationsdisclosed herein. In some embodiments, interleukin inhibitors includeWS-4 (an antibody against IL-8); [Ser IL-8]₇₂; or [Ala IL-8]₇₇ (See U.S.Pat. No. 5,451,399 which is hereby incorporated by reference fordisclosures relating to these peptides); IL-IRA; SB 265610(N-(2-Bromophenyl)-N′-(7-cyano-1H-benzotriazol-4-yl)urea); SB 225002(N-(2-Bromophenyl)-N′-(2-hydroxy-4-nitrophenyl)urea); SB203580(4-(4-Fluorophenyl)-2-(4-methylsulfinyl phenyl)-5-(4-pyridyl)1H-imidazole); SB272844 (GlaxoSmithKline); SB517785 (GlaxoSmithKline);SB656933 (GlaxoSmithKline); Sch527123(2-hydroxy-N,N-dimethyl-3-{2-[[(R)-1-(5-methyl-furan-2-yl)-propyl]amino]-3,4-dioxo-cyclobut-1-enylamino}-benzamide);PD98059(2-(2-amino-3-methoxyphenyl)-4H-1-Benzopyran-4-one); reparixin;N-[4-chloro-2-hydroxy-3-(piperazine-1-sulfonyl)phenyl]-N′-(2-chloro-3-fluorophenyl)ureap-toluenesulfonate (See WO/2007/150016 which is hereby incorporated byreference for disclosures relating to this compound); sivelestat; bG31P(CXCL8((3-74))K11R/G31P); basiliximab; cyclosporin A; SDZ RAD(40-O-(2-hydroxyethyl)-rapamycin); FR235222 (Astellas Pharma);daclizumab; anakinra; AF12198(Ac-Phe-Glu-Trp-Thr-Pro-Gly-Trp-Tyr-Gln-L-azetidine-2-carbonyl-Tyr-Ala-Leu-Pro-Leu-NH2);or combinations thereof.

Local Anesthetics

Local anesthetics are optionally used with the formulations disclosedherein. Local anesthetics include, and are not limited to, benzocaine,carticaine, cinchocaine, cyclomethycaine, lidocaine, prilocalne,propxycaine, proparacaine, tetracaine, tocamide, and trimecaine.

MAPK/JNK Signaling Cascade Inhibitors

Inhibitors of the MAPK/JNK signaling cascade are optionally used withthe formulations disclosed herein. Exemplary inhibitors of the MAPK/JNKsignaling cascade include minocycline; SB-203580(4-(4-Fluorophenyl)-2-(4-methylsulfinyl phenyl)-5-(4-pyridyl)1H-imidazole); PD 169316(4-(4-Fluorophenyl)-2-(4-nitrophenyl)-5-(4-pyridyl)-1H-imidazole); SB202190 (4-(4-Fluorophenyl)-2-(4-hydroxyphenyl)-5-(4-pyridyl)1H-imidazole); RWJ 67657(4-[4-(4-fluorophenyl)-1-(3-phenylpropyl)-5-(4-pyridinyl)-1H-imidazol-2-yl]-3-butyn-1-ol);SB 220025(5-(2-Amino-4-pyrimidinyl)-4-(4-fluorophenyl)-1-(4-piperidinyl)imidazole);or combinations thereof. Minocycline prevents the apoptosis of otic haircells following treatment with the ototoxic antibiotic gentamicin byinhibiting the induction of p38 MAPK phosphorylation. In someembodiments, the agent which antagonizes the MAPK/JNK signaling cascadeis D-JNKI-1 ((D)-hJIP₁₇₅₋₁₅₇-DPro-DPro-(D)-HIV-TAT₅₇₋₄₈), SP600125(anthra[1,9-cd]pyrazol-6(2H)-one), JNK Inhibitor I((L)-HIV-TAT₄₈₋₅₇-PP-JBD₂₀), JNK Inhibitor III((L)-HIV-TAT₄₇₋₅₇-gaba-c-Junδ₃₃₋₅₇), AS601245 (1,3-benzothiazol-2-yl(2-[[2-(3-pyridinyl)ethyl]amino]-4 pyrimidinyl)acetonitrile), JNKInhibitor VI (H₂N—RPKRPTTLNLF-NH₂), JNK Inhibitor VIII(N-(4-Amino-5-cyano-6-ethoxypyridin-2-yl)-2-(2,5-dimethoxyphenyl)acetamide),JNK Inhibitor IX(N-(3-Cyano-4,5,6,7-tetrahydro-1-benzothien-2-yl)-1-naphthamide),dicumarol (3,3′-Methylenebis(4-hydroxycoumarin)), SC-236(4-[5-(4-chlorophenyl)-3-(trifluoromethyl)-1H-pyrazol-1-yl]benzene-sulfonamide),CEP-1347 (Cephalon), CEP-11004 (Cephalon); or combinations thereof.

Neurotransmitter Reuptake Inhibitors

Neurotransmitter Reuptake Inhibitors are optionally used in theformulations disclosed herein. By way of example only, NeurotransmitterReuptake Inhibitors include amitriptyline, nortriptyline, trimipramine,fluoxetine, paroxetine, sertraline.

Nitric Oxide Synthase Inhibitors

Nitric oxide synthase (NOS) inhibitors are contemplated for use in theimmunomodulating formulations disclosed herein. NOS inhibitors are alsocontemplated as inhibitors of bone modeling in the otic capsule. NOSinhibitors include, by way of example only, aminoguanidine,1-Amino-2-hydroxyguanidine p-Toluensulfate, guanidinoethyldisulfide(GED), Bromocriptine Mesylate, Dexamethasone,N^(G),N^(G)-Dimethyl-L-arginine, Dihydrochloride, DiphenyleneiodoniumChloride, 2-Ethyl-2-thiopseudourea, haloperidol,L-N⁵-(1-Iminoethyl)ornithine, MEG, S-Methylisothiourea Sulfate (SMT),S-Methyl-L-thiocitrulline, N^(G)-Monoethyl-L-arginine,N-Monomethyl-D-arginine, N^(G)-Nitro-L-arginine Methyl Ester, L-NIL,N^(G)-Nitro-L-arginine (L-NNA), 7-Nitroindazole, nNOS Inhibitor I,1,3-PBITU, L-Thiocitrulline, N^(G)-Propyl-L-arginine, SKF-525A, TRIM,N^(G)-nitro-L-arginine methyl ester (L-NAME), MTR-105, L-NMMA, BBS-2,ONO-1714 and combinations thereof.

Ototoxic Agents

Ototoxic agents are optionally used with the formulations disclosedherein. Exemplary ototoxic agents include aminoglycoside antibiotics(e.g. gentamicin, and amikacin), the macrolide antibiotics (e.gerythromycin), the glycopeptide antibiotics (e.g. vancomycin), the loopdiuretics (e.g. furosemide) salicylic acid, and nicotine.

Platelet Activating Factor Antagonists

Platelet activating factor antagonists are also contemplated for usewith the immunomodulating formulations disclosed herein. Plateletactivating factor antagonists include, by way of example only,kadsurenone, phomactin G, ginsenosides, apafant(4-(2-chlorophenyl)-9-methyl-2[3(4-morpholinyl)-3-propanol-1-yl[6H-thieno[3,2-[[[1.2.4]triazolo]4,3-1]]1.4]diazepine),A-85783, BN-52063, BN-52021, BN-50730 (tetrahedra-4,7,8,10 methyl-1(chloro-1 phenyl)-6 (methoxy-4 phenyl-carbamoyl)-9pyrido[4′,3′-4,5]thieno[3,2-f]triazolo-1,2,4[4,3-a]diazepine-1,4), BN50739, SM-12502, RP-55778, Ro 24-4736, SR27417A, CV-6209, WEB 2086, WEB2170, 14-deoxyandrographolide, CL 184005, CV-3988, TCV-309, PMS-601,TCV-309 and combinations thereof.

Sirtuin Agonists

Sirtuin agonists are optionally used in the formulations disclosedherein. Examples of Sirtuin agonists include trans-stilbene,cis-stilbene, resveratrol, piceatannol, rhapontin, deoxyrhapontin,butein, chalcon; isoliquirtigen; butein; 4,2′,4′-trihydroxychalcone;3,4,2′,4′,6′-pentahydroxychalcone; flavone, morin, fisetin; luteolin;quercetin; kaempferol; apigenin; gossypetin; myricetin;6-hydroxyapigenin; 5-hydroxyflavone; 5,7,3′,4′,5′-pentahydroxyflavone;3,7,3′,4′,5′-pentahydroxyflavone; 3,6,3′,4′-tetrahydroxyflavone;7,3′,4′,5′-tetrahydroxyflavone; 3,6,2′,4′-tetrahydroxyflavone;7,4′-dihydroxyflavone; 7,8,3′,4′-tetrahydroxyflavone;3,6,2′,3′-tetrahydroxyflavone; 4′-hydroxyflavone; 5-hydroxyflavone;5,4′-dihydroxyflavone; 5,7-dihydroxyflavone; daidzein, genistein,naringenin; flavanone; 3,5,7,3′,4′-pentahydroxyflavanone; pelargonidinchloride, cyanidin chloride, delphinidin chloride, (−)-epicatechin(Hydroxy Sites: 3,5,7,3′,4′); (−)-catechin (Hydroxy Sites: 3,5,7,3′,4′);(−)-gallocatechin (Hydroxy Sites: 3,5,7,3′,4′,5′) (+)-catechin (HydroxySites: 3,5,7,3′,4′); (+)-epicatechin (Hydroxy Sites: 3,5,7,3′,4′);Hinokitiol (b-Thujaplicin;2-hydroxy-4-isopropyl-2,4,6-cycloheptatrien-1-one); L-(+)-Ergothioneine((S)-a-Carboxy-2,3-dihydro-N,N,N-trimethyl-2-thioxo-1H-imidazole4-ethanaminiuminner salt); Caffeic Acid Phenyl Ester; MCI-186(3-Methyl-1-phenyl-2-pyrazolin-5-one); HBED(N,N′-Di-(2-hydroxybenzyl)ethylenediamine-N,N′-diacetic acid.H2O);Ambroxol (trans-4-(2-Amino-3,5-dibromobenzylamino)cyclohexane-HCl; andU-83836E((−)-2-((4-(2,6-di-1-Pyrrolidinyl-4-pyrimidinyl)-1-piperzainyl)methyl)-3,4-dihydro-2,5,7,8-tetramethyl-2H-1-benzopyran-6-ol.2HCl);β-1′-5-methyl-nicotinamide-2′-deoxyribose;β-D-1′-5-methyl-nico-tinamide-2′-deoxyribofuranoside;β-1′-4,5-dimethyl-nicotinamide-2′-de-oxyribose; orβ-D-1′-4,5-dimethyl-nicotinamide-2′-deoxyribofuranoside; dipyridamole,ZM 336372 (3-(dimethylamino)-N-[3-[(4-hydroxybenzoyl)-amino]-4-methylphenyl]benzamide), camptothecin, coumestrol, nordihydroguaiareticacid, esculetin, SRT-1720 (Sirtris), SRT-1460 (Sirtris), SRT-2183(Sirtris), analogs thereof, or combinations thereof.

Sodium Channel Blockers

Sodium channel blocking agents are optionally used in the formulationsdisclosed herein. Sodium channel blocking agents include, but are notlimited to, vinpocetine ((3a,16a)-Eburnamenine-14-carboxylic acid ethylester); sipatrigine(2-(4-Methylpiperazin-1-yl)-5-(2,3,5-trichlorophenyl)-pyrimidin-4-amine);amiloride (3,5-diamino-N-(aminoiminomethyl)-6-chloropyrazinecarbox amidehydrochloride); carbamazepine (5H-dibenzo[b,f]azepine-5-carboxamide);TTX(octahydro-12-(hydroxymethyl)-2-imino-5,9:7,10a-dimethano-10aH-[1,3]dioxocino[6,5-d]pyrimidine-4,7,10,11,12-pentol); RS100642 (1-(2,6-dimethyl-phenoxy)-2-ethylaminopropanehydrochloride); mexiletine ((1-(2,6-dimethylphenoxy)-2-aminopropanehydrochloride)); QX-314(N-(2,6-Dimethylphenylcarbamoylmethyl)triethylammonium bromide);phenyloin (5,5-diphenylimidazolidine-2,4-dione); lamotrigine(6-(2,3-dichlorophenyl)-1,2,4-triazine-3,5-diamine); 4030W92(2,4-diamino-5-(2,3-dichlorophenyl)-6-fluoromethylpyrimidine); BW1003C87(5-(2,3,5-trichlorophenyl) pyrimidine-2,4-1.1 ethanesulphonate); QX-222(2-[(2,6-dimethylphenyl)amino]-N,N,N-trimethyl-2-oxoetha niminiumchloride); ambroxol(trans-4-[[(2-Amino-3,5-dibromophenyl)methyl]amino]cyclo hexanolhydrochloride); R56865(N-[1-(4-(4-fluorophenoxy)butyl]-4-piperidinyl-N-methyl-2-benzo-thiazolamine);lubeluzole; ajmaline ((17R,21 alpha)-ajmalan-17,21-diol); procainamide(4-amno-N-(2-diethylaminoethyl)benzamide hydrochloride); flecainide;riluzoleor; or combinations thereof.

Src Antagonists

SRC antagonists are optionally used with the formulations disclosedherein. Src antagonists are also contemplated as modulators of boneremodeling in the otic capsule. SRC antagonists include, and are notlimited to, 1-Naphthyl PP1(1-(1,1-Dimethylethyl)-3-(1-naphthalenyl)-1H-pyrazolo[3,4-d]pyrimidin-4-amine);Lavendustin A(5-[[(2,5-Dihydroxyphenyl)methyl][(2-hydroxyphenyl)methyl]amino]-2-hydroxybenzoicacid); MNS (3,4-Methylenedioxy-b-nitrostyrene);PP1(1-(1,1-Dimethylethyl)-1-(4-methylphenyl)-1H-pyrazolo[3,4-d]pyrimidin-4-amine);PP2 (3-(4-chlorophenyl)1-(1,1-dimethylethyl)-1H-pyrazolo[3,4-d]pyrimidin-4-amine); KX1-004(Kinex); KX1-005 (Kinex); KX1-136 (Kinex); KX1-174 (Kinex); KX1-141(Kinex); KX2-328 (Kinex); KX1-306 (Kinex); KX1-329 (Kinex); KX2-391(Kinex); KX2-377 (Kinex); ZD4190 (Astra Zeneca;N-(4-bromo-2-fluorophenyl)-6-methoxy-7-(2-(1H-1,2,3-triazol-1-yl)ethoxy)quinazolin-4-amine);AP22408 (Ariad Pharmaceuticals); AP23236 (Ariad Pharmaceuticals);AP23451 (Ariad Pharmaceuticals); AP23464 (Ariad Pharmaceuticals);AZD0530 (Astra Zeneca); AZM475271 (M475271; Astra Zeneca); Dasatinib(N-(2-chloro-6-methylphenyl)-2-(6-(4-(2-hydroxyethyl)-piperazin-1-yl)-2-methylpyrimidin-4-ylamino)thiazole-5-carboxamide); GN963(trans-4-(6,7-dimethoxyquinoxalin-2-ylamino)cyclohexanol sulfate);Bosutinib(4-((2,4-dichloro-5-methoxyphenyl)amino)-6-methoxy-7-(3-(4-methyl-1-piperazinyl)propoxy)-3-quinolinecarbonitrile);CPG-77675; or combinations thereof. For disclosure of additionalantagonists of the Src family of kinases, see U.S. Pub. No.2006/0172971, which is hereby incorporated by reference for thosedisclosures.

TACE Inhibitors

TACE inhibitors are optionally used in the formulations disclosedherein. Examples of TACE inhibitors include Nitroarginine analog A,GW3333, TMI-1, BMS-561392, DPC-3333, TMI-2, BMS-566394, TMI-005,apratastat, GW4459, W-3646, IK-682, GI-5402, GI-245402, BB-2983,DPC-A38088, DPH-067517, R-618, and CH-138.

Thyroid Hormone Receptor Modulation

Thyroid Hormone Receptor modulating agents are optionally used with theformulations disclosed herein. In some instances, Thyroid HormoneReceptor modulating agents include T₃ (3,5,3′-triiodo-L-thyronine);KB-141 (3,5-dichloro-4-(4-hydroxy-3-isopropylphenoxy)phenylacetic acid);GC-1 (3,5-dimethyl-4-(4′-hydroxy-3′-isopropylbenzyl)-phenoxy aceticacid); GC-24 (3,5-dimethyl-4-(4′-hydroxy-3′-benzyl)benzylphenoxyaceticacid); sobetirome (QRX-431); 4-OH—PCB106(4-OH-2′,3,3′,4′,5′-pentachlorobiphenyl); MB07811((2R,4S)-4-(3-chlorophenyl)-2-[(3,5-dimethyl-4-(4-hydroxy-3-isopropylbenzyl)phenoxy)methyl]-2-oxido-[1,3,2]-dioxaphosphonane);MB07344(3,5-dimethyl-4-(4-hydroxy-3-isopropylbenzyl)phenoxy)methylphosphonicacid); and combinations thereof. In certain instances, KB-141; GC-1;sobetirome; and GC-24 are selective for TRβ.

Toll-Like Receptor Inhibitors

Toll-like receptor (TLR) inhibitors are optionally used in theformulations disclosed herein. By way of example, TLR inhibitors includeST2 antibody; sST2-Fc (functional murine soluble ST2-human IgG1 Fcfusion protein; see Biochemical and Biophysical Research Communications,29 Dec. 2006, vol. 351, no. 4, 940-946 which is herein incorporated byreference for disclosures related to sST2-Fc); CRX-526 (Corixa); lipidIV_(A); RSLA (Rhodobacter sphaeroides lipid A); E5531((6-O-{2-deoxy-6-O-methyl-4-O-phosphono-3-O—[(R)-3-Z-dodec-5-endoyloxydecl]-2-[3-oxo-tetradecanoylamino]-β-O-phosphono-α-D-glucopyranosetetrasodium salt); E5564(α-D-Glucopyranose,3-O-decyl-2-deoxy-6-O-[2-deoxy-3-O-[(3R)-3-methoxydecyl]-6-O-methyl-2-[[(11Z)-1-oxo-11-octadecenyl]amino]-4-O-phosphono-β-D-glucopyranosyl]-2-[(1,3-dioxotetradecyl)amino]-1-(dihydrogenphosphate), tetrasodium salt); compound 4a (hydrocinnamoyl-L-valylpyrrolidine; see PNAS, Jun. 24, 2003, vol. 100, no. 13, 7971-7976 whichis herein incorporated by reference for disclosures related to compound4a); CPG 52364 (Coley Pharmaceutical Group); LY294002(2-(4-Morpholinyl)-8-phenyl-4H-1-benzopyran-4-one); PD98059(2-(2-amino-3-methoxyphenyl)-4H-1-Benzopyran-4-one); chloroquine; and animmune regulatory oligonucleotide (for disclosures relating to IROs seeU.S. Patent Application Publication No. 2008/0089883).

TNF Antagonists

Anti-TNF agents are also contemplated as useful with the formulationsdisclosed herein. Anti-TNF agents are also contemplated as useful inmodulation of bone remodeling in the otic capsule. Anti-TNF agentsinclude, by way of example, etanercept (ENBREL®), infliximab(REMICADE®), adalimumab (HUMIRA®), and golimumab (CNTO 148), TNFreceptors (pegylated soluble TNF receptor type 1; Amgen); TNF bindingfactors (Onercept; Serono); TNF antibodies (US Patent App. No.2005/0123541; US Patent App. No. 2004/0185047); single domain antibodiesagainst the p55 TNF receptor (US Patent App. No. 2008/00088713); solubleTNF receptors (US Patent App. No. 2007/0249538); fusion polypeptidesbinding to TNF (US Patent App. No. 2007/0128177); TNF-converting enzymeinhibitors (Skotnicki et al., Annual Reports in Medicinal Chemistry(2003), 38, 153-162); IKK inhibitors (Karin et al., Nature Reviews DrugDiscovery (2004), 3, 17-26) and flavone derivatives (US Patent App. No.2006/0105967), all of which are incorporated by reference for suchdisclosure.

Estrogen Receptor Modulators

Estrogen Receptor Modulators are optionally used in the formulationsdisclosed herein and are also contemplated as modulators of boneremodeling in the otic capsule. Estrogen receptor modulators include,and are not limited to, afimoxifene (4-hydroxytamoxifen); arzoxifene;bazedoxifene; clomifene; femarelle (DT56a); lasofoxifene; ormeloxifene;ospemifine; raloxifene; tamoxifen; GW5638; LY353381; ICI 182,780(fulvestrant, FASLODEX®); isoflavones, and SR16234.

Bisphosphonates

Bisphosphonates are optionally used in the formulations disclosedherein. Bisphosphonates are contemplated as modulators of boneremodeling in the otic capsule. Examples of Bisphosphonates includeEtidronate (DIDRONEL®); Clodronate (BONEFOS®); Tiludronate (SKELID®);Pamidronate (APD, AREDIA®); Neridronate; Olpadronate; Alendronate(FOSFAMAX®); Ibandronate (BONIVA®); Risedronate (ACTONEL®); Zoledronate(ZOMETA®).

Carbonic Anhydrase Inhibitors

Carbonic anhydrase inhibitors are optionally used in the formulationsdisclosed herein. Carbonic anhydrase inhibitors are also contemplated asmodulators of bone remodeling in the otic capsule. Exemplary carbonicanhydrase inhibitors include Acetazolamide, Brinzolamide, Methazolamide,Dorzolamide, Sezolamide, Topiramate, MK-927, MK-417, and MK-507.

Matrix MetalloProteinase Modulators

Matrix metalloproteinase inhibitors are optionally used in theformulations disclosed herein. Matrix metalloproteinase inhibitors arealso contemplated as modulators of bone remodeling in the otic capsule.Matrix metalloproteinase inhibitors include, and are not limited to, Ro28-2653; MMI-166; MMI270 (CGS27023A), COL-3 (NSC-683551), PG-530742,S-3304, and ACZ885.

Cathepsin K Inhibitors and Protease Inhibitors

Cathepsin K inhibitors are optionally used in the formulations disclosedherein. Cathepsin K inhibitors and other protease inhibitors are alsocontemplated as modulators of bone remodeling in the otic capsule.Examples of Cathepsin K inhibitors include balicatib, odanacatib(MK-0822), CRA-013783/L-006235, AAE581, and MK886. Other proteaseinhibitors include, by way of example, Saquinavir (FORTOVASE®,INVIRASE®); Ritonavir (NORVIR®); Indinavir (CRIXIVAN®); Nelfinavir(VIRACEPT®); Amprenavir (AGENERASE®); Lopinavir (KALETRA®); Atazanavir(REYATAZ®); Fosamprenavir (LEXIVA®); Tipranavir (APTIVUS®); Darunavir(PREZISTA®) and cystatin B.

Leukotriene Inhibitors

Leukotriene inhibitors are optionally used in the formulations disclosedherein. Leukotriene inhibitors are also contemplated as modulators ofbone remodeling in the otic capsule and include, by way of example, BAYX1005, montelukast, zafirlukast, LY-171,883 (tomelukast), and zileuton.

Lipoxygenase Inhibitors and Protein Prenylation Inhibitors

Lipoxygenase inhibitors are optionally used in the formulationsdisclosed herein and are also contemplated as modulators of boneremodeling in the otic capsule. Lipoxygenase inhibitors include, and arenot limited to, azelastine; diethylcarbamazine; nordihydroguaiareticacid; zileuton; A63162; and A-64077. Other protein prenylationinhibitors are also contemplated as modulators of bone remodeling in theotic capsule including farnesyl transferase inhibitors R115777(tipifarnib), BMS-214662, CP-609,754, and SCH66336 (lonafarnib).

RANKL Modulators

RANKL inhibitors are optionally used in the formulations disclosedherein and are contemplated as modulators of bone remodeling in the oticcapsule. Exemplary RANKL modulators include denosumab (AMG-162), andSCIO-469.

Aromatase Inhibitors

Aromatase inhibitors are optionally used in the formulations disclosedherein and are contemplated as modulators of bone remodeling in the oticcapsule. Aromatase inhibitors include, by way of example, 40Handrostenedione; AROMASIN® (exemestane); FEMARA® (letrozole); andARIMIDEX® (anastrozole).

COX-2 Inhibitors

COX-2 inhibitors are optionally used in the formulations disclosedherein and are contemplated as modulators of bone remodeling in the oticcapsule. Examples of COX-2 inhibitors include, and are not limited to,celecoxib (CELEBREX®), rofecoxib (VIOXX®), valdecoxib (BEXTRA®);aspirin; ibuprofen, meloxicam and naproxen.

Adenylyl Cyclase (AC) Modulators

AC inhibitors are optionally used in the formulations disclosed hereinand are contemplated as modulators of bone remodeling in the oticcapsule. AC modulators include hormones such as parathyroid hormone andanalogues thereof including the analogues disclosed in U.S. Pat. No.6,541,450, which is herein incorporated by reference.

Hormones

Hormones are optionally used in the formulations disclosed herein andare contemplated as modulators of bone remodeling in the otic capsule.Exemplary hormones include parathyroid hormone (PTH) and analoguesthereof, vitamin D and analogues thereof; calcitonin; growth factorsincluding IL-6, CSF; and estrogen.

PPAR γ Modulators

PPAR γ modulators are optionally used in the formulations disclosedherein and are contemplated as modulators of bone remodeling in the oticcapsule. Non-limiting examples of PPAR γ modulators includerosiglitazone, pioglitazone, GW9662, SR-202, ciglitazone, troglitazone,GW1929, GW7647

RNAi

In some embodiments, where inhibition or down-regulation of a target isdesired (e.g. genes in the MAPK/JNK cascade, caspase genes, Src genes,calpain genes, Ca²⁺ channel genes), RNA interference may be utilized. Insome embodiments, the agent that inhibits or down-regulates the targetis an siRNA molecule. In certain instances, the siRNA molecule inhibitsthe transcription of a target by RNA interference (RNAi). In someembodiments, a double stranded RNA (dsRNA) molecule with sequencescomplementary to a target is generated (e.g by PCR). In someembodiments, a 20-25 bp siRNA molecule with sequences complementary to atarget is generated. In some embodiments, the 20-25 bp siRNA moleculehas 2-5 bp overhangs on the 3′ end of each strand, and a 5′ phosphateterminus and a 3′ hydroxyl terminus. In some embodiments, the 20-25 bpsiRNA molecule has blunt ends. For techniques for generating RNAsequences see Molecular Cloning: A Laboratory Manual, second edition(Sambrook et al., 1989) and Molecular Cloning: A Laboratory Manual,third edition (Sambrook and Russel, 2001), jointly referred to herein as“Sambrook”); Current Protocols in Molecular Biology (F. M. Ausubel etal., eds., 1987, including supplements through 2001); Current Protocolsin Nucleic Acid Chemistry John Wiley & Sons, Inc., New York, 2000) whichare hereby incorporated by reference for such disclosure.

In some embodiments, the dsRNA or siRNA molecule is incorporated into acontrolled-release auris-acceptable microsphere or microparticle,hydrogel, liposome, or thermoreversible gel. In some embodiments, theauris-acceptable microsphere, hydrogel, liposome, paint, foam, in situforming spongy material, nanocapsule or nanosphere or thermoreversiblegel is injected into the inner ear. In some embodiments, theauris-acceptable microsphere or microparticle, hydrogel, liposome, orthermoreversible gel. In some embodiments, the auris-acceptablemicrosphere, hydrogel, liposome, paint, foam, in situ forming spongymaterial, nanocapsule or nanosphere or thermoreversible gel is injectedinto the cochlea, the organ of Corti, the vestibular labyrinth, or acombination thereof.

In certain instances, after administration of the dsRNA or siRNAmolecule, cells at the site of administration (e.g. the cells ofcochlea, organ of Corti, and/or the vestibular labyrinth) aretransformed with the dsRNA or siRNA molecule. In certain instancesfollowing transformation, the dsRNA molecule is cleaved into multiplefragments of about 20-25 bp to yield siRNA molecules. In certaininstances, the fragments have about 2 bp overhangs on the 3′ end of eachstrand.

In certain instances, an siRNA molecule is divided into two strands (theguide strand and the anti-guide strand) by an RNA-induced SilencingComplex (RISC). In certain instances, the guide strand is incorporatedinto the catalytic component of the RISC (i.e. argonaute). In certaininstances, the guide strand binds to a complementary target mRNAsequence. In certain instances, the RISC cleaves the target mRNA. Incertain instances, the expression of the target gene is down-regulated.

In some embodiments, a sequence complementary to a target is ligatedinto a vector. In some embodiments, the sequence is placed between twopromoters. In some embodiments, the promoters are orientated in oppositedirections. In some embodiments, the vector is contacted with a cell. Incertain instances, a cell is transformed with the vector. In certaininstances following transformation, sense and anti-sense strands of thesequence are generated. In certain instances, the sense and anti-sensestrands hybridize to form a dsRNA molecule which is cleaved into siRNAmolecules. In certain instances, the strands hybridize to form an siRNAmolecule. In some embodiments, the vector is a plasmid (e.g., pSUPER;pSUPER.neo; pSUPER.neo+gfp).

In some embodiments, the vector is incorporated into acontrolled-release auris-acceptable microsphere or microparticle,hydrogel, liposome, or thermoreversible gel. In some embodiments, theauris-acceptable microsphere, hydrogel, liposome, paint, foam, in situforming spongy material, nanocapsule or nanosphere or thermoreversiblegel is injected into the inner ear. In some embodiments, theauris-acceptable microsphere or microparticle, hydrogel, liposome, orthermoreversible gel. In some embodiments, the auris-acceptablemicrosphere, hydrogel, liposome, paint, foam, in situ forming spongymaterial, nanocapsule or nanosphere or thermoreversible gel is injectedinto the cochlea, the organ of Corti, the vestibular labyrinth, or acombination thereof.

Statins

Statins (or HMG-CoA reductase inhibitors) are optionally used in theformulations disclosed herein and are contemplated as modulators of boneremodeling in the otic capsule. Statins include, by way of example,Atorvastatin (LIPITOR®, TORVAST®); Cerivastatin (LIPOBAY®, BAYCOL®);Fluvastatin (LESCOL®); Lovastatin (MEVACOR®, ALTOCOR®, ALTOPREV®);Mevastatin; Pitavastatin (LIVALO®, PITAVA®); Pravastatin (PRAVACHOL®,SELEKTINE®, LIPOSTAT®); Rosuvastatin (CRESTOR®); Simvastatin (ZOCOR®);Simvastatin+Ezetimibe (VYTORIN®); Lovastatin+Niacin (ADVICOR®Combination therapy); Atorvastatin+Amlodipine Besylate (CADUET®Combination therapy); Simvastatin+Niacin (SIMCOR® Combination therapy).

TRACP Modulators

TRACP modulators are optionally used in the formulations disclosedherein and are contemplated as modulators of bone remodeling in the oticcapsule. TRACP modulators include, by way of example only, cystatin B.

TGF β Modulators

TGF β inhibitors are optionally used in the formulations disclosedherein and are contemplated as modulators of bone remodeling in the oticcapsule. TGF β inhibitors include, and are not limited to, CAT-192(Human Anti-TGF-Beta1 Monoclonal Antibody); GC1008 (humananti-transforming growth factor-beta (TGFβ) monoclonal antibody); andother small molecule modulators of TGF β disclosed in Yingling et al.,Nature Reviews, 2004, 3, 1011-1022, which is incorporated by referenceherein.

TRPV Modulation

TRPV modulating agents are optionally used with the formulationsdisclosed herein. Examples of TRPV modulating agents include capsaicin,resiniferatoxin, the TRPV modulators disclosed in US applicationpublications 2005/0277643, 2005/0215572, 2006/0194801, 2006/0205773,2006/0194801, 2008/0175794, 2008/0153857, 2008/0085901, 20080015183,2006/0030618, 2005/0277646, 2005/0277631, 2005/0272931, 2005/0227986,2005/0153984, 2006/0270682, 2006/0211741, 2006/0205980, and2006/0100490, and/or combinations thereof.

Presented below (Table 1) are examples of active agents contemplated foruse with the compositions and devices disclosed herein. In someembodiments, one or more active agents disclosed in Table 1 are used ina composition or device described herein.

TABLE 1 Auris Condition Therapeutic Agent Benign ParoxysmalDiphenhydramine Positional Vertigo Benign Paroxysmal LorazepamPositional Vertigo Benign Paroxysmal Meclizine Positional Vertigo BenignParoxysmal Oldansetron Positional Vertigo Hearing Loss Estrogen AIEDEtanercept (Enbrel) AIED GW3333 AIED Copaxone Hearing Loss Estrogen andprogesterone (E + P) Hearing Loss Folic acid Hearing Loss LactatedRinger's with 0.03% Ofloxacin Hearing Loss Methotrexate Hearing LossN-acetyl cysteine Meniere's Disease Betahistine Meniere's DiseaseSildenafil Meniere's Disease Tacrolimus Middle Ear EffusionPneumonococcal vaccine Otitis Externa Diclofenac sodium; dexotc OtitisExterna, AL-15469A/AL-38905 Acute Otitis Media Amoxicillin/clavulanateOtitis Media Dornase alfa Otitis Media Echinacea purpurea Otitis MediaFaropenem medoxomil Otitis Media Levofloxacin Otitis Media PNCRM9 OtitisMedia Pneumococcal vaccine Otitis Media Telithromycin Otitis Media ZmaxOtitis Media with Lansoprazole Effusion Otitis Media, Acute AL-15469A;AL-38905 Otitis Media, Acute Amoxicillin Otitis Media, AcuteAmoxicillin-clavulanate Otitis Media, Acute Azithromycin Otitis Media,Acute Azithromycin SR Otitis Media, Acute Cefdinir Otitis Media, AcuteHyland's earache drops Otitis Media, Acute Montelukast Otitis Media,Acute Pneumonococcal vaccine Otitis Media, Acute AL-15469A/AL38905 withTypanostomy Tubes Otitis Media, Sulfamethoxazole- Chronic trimethoprimOtitis Media, Azithromycin Suppurative Otitis Media, TelithromycinSuppurative Otosclerosis Acetylcysteine Ototoxicity Aspirin TinnitusAcamprosate Tinnitus Gabapentin Tinnitus Modafinil Tinnitus NeramexaneTinnitus Neramexane mesylate Tinnitus Piribedil Tinnitus VardenafilTinnitus Vestipitant + Paroxetine Tinnitus Vestiplitant Tinnitus Zincsulfate

In some embodiments, the additional therapeutic agent is an immediaterelease agent. In some embodiments, the additional therapeutic agent isa controlled-release agent.

General Methods of Sterilization

Provided herein are otic compositions that ameliorate or lessen oticdisorders described herein. Further provided herein, in someembodiments, are methods comprising the administration of said oticcompositions. In some embodiments, the compositions or devices aresterilized. Included within the embodiments disclosed herein are meansand processes for sterilization of a pharmaceutical composition ordevice disclosed herein for use in humans. The goal is to provide a safepharmaceutical product, relatively free of infection causingmicro-organisms. The U.S. Food and Drug Administration has providedregulatory guidance in the publication “Guidance for Industry: SterileDrug Products Produced by Aseptic Processing” available at:http://www.fda.gov/cder/guidance/5882fnl.htm, which is incorporatedherein by reference in its entirety.

As used herein, “sterilization” means a process used to destroy orremove microorganisms that are present in a product or packaging. Anysuitable method available for sterilization of objects and compositionsis contemplated for use with the compositions and devices disclosedherein. Available methods for the inactivation of microorganismsinclude, but are not limited to, the application of extreme heat, lethalchemicals, or gamma radiation. Disclosed herein, in some embodiments,are processes for the preparation of an otic therapeutic compositioncomprising subjecting the composition to a sterilization method selectedfrom heat sterilization, chemical sterilization, radiation sterilizationor filtration sterilization. The method used depends largely upon thenature of the device or composition to be sterilized. Detaileddescriptions of many methods of sterilization are given in Chapter 40 ofRemington: The Science and Practice of Pharmacy published by Lippincott,Williams & Wilkins, and is incorporated by reference with respect tothis subject matter.

Sterilization by Heat

Many methods are available for sterilization by the application ofextreme heat. One method is through the use of a saturated steamautoclave. In this method, saturated steam at a temperature of at least121° C. is allowed to contact the object to be sterilized. The transferof heat is either directly to the microorganism, in the case of anobject to be sterilized, or indirectly to the microorganism by heatingthe bulk of an aqueous solution to be sterilized. This method is widelypracticed as it allows flexibility, safety and economy in thesterilization process.

Dry heat sterilization is a method that is used to kill microorganismsand perform depyrogenation at elevated temperatures. This process takesplace in an apparatus suitable for heating HEPA-filteredmicroorganism-free air to temperatures of at least 130-180° C. for thesterilization process and to temperatures of at least 230-250° C. forthe depyrogenation process. Water to reconstitute concentrated orpowdered compositions is also sterilized by autoclave. In someembodiments, the compositions described herein comprise micronizedpharmaceutical that are sterilized by dry heating, e.g., heating forabout 7-11 hours at internal powder temperatures of 130-140° C., or for1-2 hours at internal temperatures of 150-180° C.

Chemical Sterilization

Chemical sterilization methods are an alternative for products that donot withstand the extremes of heat sterilization. In this method, avariety of gases and vapors with germicidal properties, such as ethyleneoxide, chlorine dioxide, formaldehyde or ozone are used as theanti-apoptotic agents. The germicidal activity of ethylene oxide, forexample, arises from its ability to serve as a reactive alkylatingagent. Thus, the sterilization process requires the ethylene oxidevapors to make direct contact with the product to be sterilized.

Radiation Sterilization

One advantage of radiation sterilization is the ability to sterilizemany types of products without heat degradation or other damage. Theradiation commonly employed is beta radiation or alternatively, gammaradiation from a ⁶⁰Co source. The penetrating ability of gamma radiationallows its use in the sterilization of many product types, includingsolutions, compositions and heterogeneous mixtures. The germicidaleffects of irradiation arise from the interaction of gamma radiationwith biological macromolecules. This interaction generates chargedspecies and free radicals. Subsequent chemical reactions, such asrearrangements and cross-linking processes, result in the loss of normalfunction for these biological macromolecules. The compositions describedherein are also optionally sterilized using beta irradiation.

Filtration

Filtration sterilization is a method used to remove but not destroymicroorganisms from solutions. Membrane filters are used to filterheat-sensitive solutions. Such filters are thin, strong, homogenouspolymers of mixed cellulosic esters (MCE), polyvinylidene fluoride (PVF;also known as PVDF), or polytetrafluoroethylene (PTFE) and have poresizes ranging from 0.1 to 0.22 μm. Solutions of various characteristicsare optionally filtered using different filter membranes. For example,PVF and PTFE membranes are well suited to filtering organic solventswhile aqueous solutions are filtered through PVF or MCE membranes.Filter apparatus are available for use on many scales ranging from thesingle point-of-use disposable filter attached to a syringe up tocommercial scale filters for use in manufacturing plants. The membranefilters are sterilized by autoclave or chemical sterilization.Validation of membrane filtration systems is performed followingstandardized protocols (Microbiological Evaluation of Filters forSterilizing Liquids, Vol 4, No. 3. Washington, D.C: Health IndustryManufacturers Association, 1981) and involve challenging the membranefilter with a known quantity (ca. 10⁷ cm²) of unusually smallmicroorganisms, such as Brevundimonas diminuta (ATCC 19146).

Pharmaceutical compositions are optionally sterilized by passing throughmembrane filters. Compositions comprising nanoparticles (U.S. Pat. No.6,139,870) or multilamellar vesicles (Richard et al., InternationalJournal of Pharmaceutics (2006), 312(1-2): 144-50) are amenable tosterilization by filtration through 0.22 m filters without destroyingtheir organized structure.

In some embodiments, the methods disclosed herein comprise sterilizingthe composition (or components thereof) by means of filtrationsterilization. In another embodiment the auris-acceptable otictherapeutic agent composition comprises a particle wherein the particlecomposition is suitable for filtration sterilization. In a furtherembodiment said particle composition comprises particles of less than300 nm in size, of less than 200 nm in size, of less than 100 nm insize. In another embodiment the auris-acceptable composition comprises aparticle composition wherein the sterility of the particle is ensured bysterile filtration of the precursor component solutions. In anotherembodiment the auris-acceptable composition comprises a particlecomposition wherein the sterility of the particle composition is ensuredby low temperature sterile filtration. In a further embodiment, lowtemperature sterile filtration is carried out at a temperature between 0and 30° C., between 0 and 20° C., between 0 and 10° C., between 10 and20° C., or between 20 and 30° C.

In another embodiment is a process for the preparation of anauris-acceptable particle composition comprising: filtering the aqueoussolution containing the particle composition at low temperature througha sterilization filter; lyophilizing the sterile solution; andreconstituting the particle composition with sterile water prior toadministration. In some embodiments, a composition described herein ismanufactured as a suspension in a single vial composition containing themicronized active pharmaceutical ingredient. A single vial compositionis prepared by aseptically mixing a sterile poloxamer solution withsterile micronized active ingredient (e.g., PD98059) and transferringthe composition to sterile pharmaceutical containers. In someembodiments, a single vial containing a composition described herein asa suspension is resuspended before dispensing and/or administration.

In specific embodiments, filtration and/or filling procedures arecarried out at about 5° C. below the gel temperature (T_(gel)) of acomposition described herein and with viscosity below a theoreticalvalue of 100 cP to allow for filtration in a reasonable time using aperistaltic pump.

In another embodiment the auris-acceptable otic therapeutic agentcomposition comprises a nanoparticle composition wherein thenanoparticle composition is suitable for filtration sterilization. In afurther embodiment the nanoparticle composition comprises nanoparticlesof less than 300 nm in size, of less than 200 nm in size, or of lessthan 100 nm in size. In another embodiment the auris-acceptablecomposition comprises a microsphere composition wherein the sterility ofthe microsphere is ensured by sterile filtration of the precursororganic solution and aqueous solutions. In another embodiment theauris-acceptable composition comprises a thermoreversible gelcomposition wherein the sterility of the gel composition is ensured bylow temperature sterile filtration. In a further embodiment, the lowtemperature sterile filtration occurs at a temperature between 0 and 30°C., or between 0 and 20° C., or between 0 and 10° C., or between 10 and20° C., or between 20 and 30° C. In another embodiment is a process forthe preparation of an auris-acceptable thermoreversible gel compositioncomprising: filtering the aqueous solution containing thethermoreversible gel components at low temperature through asterilization filter; lyophilizing the sterile solution; andreconstituting the thermoreversible gel composition with sterile waterprior to administration.

In certain embodiments, the active ingredients are dissolved in asuitable vehicle (e.g. a buffer) and sterilized separately (e.g. by heattreatment, filtration, gamma radiation). In some instances, the activeingredients are sterilized separately in a dry state. In some instances,the active ingredients are sterilized as a suspension or as a colloidalsuspension. The remaining excipients (e.g., fluid gel components presentin auris compositions) are sterilized in a separate step by a suitablemethod (e.g. filtration and/or irradiation of a cooled mixture ofexcipients); the two solutions that are separately sterilized are thenmixed aseptically to provide a final auris composition. In someinstances, the final aseptic mixing is performed just prior toadministration of a composition described herein.

In some instances, conventionally used methods of sterilization (e.g.,heat treatment (e.g., in an autoclave), gamma irradiation, filtration)lead to irreversible degradation of polymeric components (e.g.,thermosetting, gelling or mucoadhesive polymer components) and/or theactive agent in the composition. In some instances, sterilization of anauris composition by filtration through membranes (e.g., 0.2 μMmembranes) is not possible if the composition comprises thixotropicpolymers that gel during the process of filtration.

Accordingly, provided herein are methods for sterilization of auriscompositions that prevent degradation of polymeric components (e.g.,thermosetting and/or gelling and/or mucoadhesive polymer components)and/or the active agent during the process of sterilization. In someembodiments, degradation of the active agent (e.g., any therapeutic oticagent described herein) is reduced or eliminated through the use ofspecific pH ranges for buffer components and specific proportions ofgelling agents in the compositions. In some embodiments, the choice ofan appropriate gelling agent and/or thermosetting polymer allows forsterilization of compositions described herein by filtration. In someembodiments, the use of an appropriate thermosetting polymer and anappropriate copolymer (e.g., a gelling agent) in combination with aspecific pH range for the composition allows for high temperaturesterilization of compositions described with substantially nodegradation of the therapeutic agent or the polymeric excipients. Anadvantage of the methods of sterilization provided herein is that, incertain instances, the compositions are subjected to terminalsterilization via autoclaving without any loss of the active agentand/or excipients and/or polymeric components during the sterilizationstep and are rendered substantially free of microbes and/or pyrogens.

Microorganisms

Provided herein are auris-acceptable compositions or devices thatameliorate or lessen otic disorders described herein. Further providedherein are methods comprising the administration of said oticcompositions. In some embodiments, the compositions or devices aresubstantially free of microorganisms. Acceptable sterility levels arebased on applicable standards that define therapeutically acceptableotic compositions, including but not limited to United StatesPharmacopeia Chapters <1111> et seq. For example, acceptable sterilitylevels include about 10 colony forming units (cfu) per gram ofcomposition, about 50 cfu per gram of composition, about 100 cfu pergram of composition, about 500 cfu per gram of composition or about 1000cfu per gram of composition. In some embodiments, acceptable sterilitylevels for compositions include less than 10 cfu/mL, less that 50cfu/mL, less than 500 cfu/mL or less than 1000 cfu/mL microbial agents.In addition, acceptable sterility levels include the exclusion ofspecified objectionable microbiological agents. By way of example,specified objectionable microbiological agents include but are notlimited to Escherichia coli (E. coli), Salmonella sp., Pseudomonasaeruginosa (P. aeruginosa) and/or other specific microbial agents.

Sterility of the auris-acceptable otic therapeutic agent composition isconfirmed through a sterility assurance program in accordance withUnited States Pharmacopeia Chapters <61>, <62> and <71>. A key componentof the sterility assurance quality control, quality assurance andvalidation process is the method of sterility testing. Sterilitytesting, by way of example only, is performed by two methods. The firstis direct inoculation wherein a sample of the composition to be testedis added to growth medium and incubated for a period of time up to 21days. Turbidity of the growth medium indicates contamination. Drawbacksto this method include the small sampling size of bulk materials thatreduces sensitivity, and detection of microorganism growth based on avisual observation. An alternative method is membrane filtrationsterility testing. In this method, a volume of product is passed througha small membrane filter paper. The filter paper is then placed intomedia to promote the growth of microorganisms. This method has theadvantage of greater sensitivity as the entire bulk product is sampled.The commercially available Millipore Steritest sterility testing systemis optionally used for determinations by membrane filtration sterilitytesting. For the filtration testing of creams or ointments Steritestfilter system No. TLHVSL210 are used. For the filtration testing ofemulsions or viscous products Steritest filter system No. TLAREM210 orTDAREM210 are used. For the filtration testing of pre-filled syringesSteritest filter system No. TTHASY210 are used. For the filtrationtesting of material dispensed as an aerosol or foam Steritest filtersystem No. TTHVA210 are used. For the filtration testing of solublepowders in ampoules or vials Steritest filter system No. TTHADA210 orTTHADV210 are used.

Testing for E. coli and Salmonella includes the use of lactose brothsincubated at 30-35° C. for 24-72 hours, incubation in MacConkey and/orEMB agars for 18-24 hours, and/or the use of Rappaport medium. Testingfor the detection of P. aeruginosa includes the use of NAC agar. UnitedStates Pharmacopeia Chapter <62> further enumerates testing proceduresfor specified objectionable microorganisms.

In certain embodiments, any controlled-release composition describedherein has less than about 60 colony forming units (CFU), less thanabout 50 colony forming units, less than about 40 colony forming units,or less than about 30 colony forming units of microbial agents per gramof composition. In certain embodiments, the otic compositions describedherein are formulated to be isotonic with the endolymph and/or theperilymph.

Endotoxins

Provided herein are otic compositions that ameliorate or lessen oticdisorders described herein. Further provided herein are methodscomprising the administration of said otic compositions. In someembodiments, the compositions or devices are substantially free ofendotoxins. An additional aspect of the sterilization process is theremoval of by-products from the killing of microorganisms (hereinafter,“Product”). The process of depyrogenation removes pyrogens from thesample. Pyrogens are endotoxins or exotoxins that induce an immuneresponse. An example of an endotoxin is the lipopolysaccharide (LPS)molecule found in the cell wall of gram-negative bacteria. Whilesterilization procedures such as autoclaving or treatment with ethyleneoxide kill the bacteria, the LPS residue induces a proinflammatoryimmune response, such as septic shock. Because the molecular size ofendotoxins can vary widely, the presence of endotoxins is expressed in“endotoxin units” (EU). One EU is equivalent to 100 picograms of E. coliLPS. Humans can develop a response to as little as 5 EU/kg of bodyweight. The sterility is expressed in any units as recognized in theart. In certain embodiments, otic compositions described herein containlower endotoxin levels (e.g. <4 EU/kg of body weight of a subject) whencompared to conventionally acceptable endotoxin levels (e.g., 5 EU/kg ofbody weight of a subject). In some embodiments, the auris-acceptableotic therapeutic agent composition has less than about 5 EU/kg of bodyweight of a subject. In other embodiments, the auris-acceptable otictherapeutic agent composition has less than about 4 EU/kg of body weightof a subject. In additional embodiments, the auris-acceptable otictherapeutic agent composition has less than about 3 EU/kg of body weightof a subject. In additional embodiments, the auris-acceptable otictherapeutic agent composition has less than about 2 EU/kg of body weightof a subject.

In some embodiments, the auris-acceptable otic therapeutic agentcomposition or device has less than about 5 EU/kg of composition. Inother embodiments, the auris-acceptable otic therapeutic agentcomposition has less than about 4 EU/kg of composition. In additionalembodiments, the auris-acceptable otic therapeutic agent composition hasless than about 3 EU/kg of composition. In some embodiments, theauris-acceptable otic therapeutic agent composition has less than about5 EU/kg Product. In other embodiments, the auris-acceptable otictherapeutic agent composition has less than about 1 EU/kg Product. Inadditional embodiments, the auris-acceptable otic therapeutic agentcomposition has less than about 0.2 EU/kg Product. In some embodiments,the auris-acceptable otic therapeutic agent composition has less thanabout 5 EU/g of unit or Product. In other embodiments, theauris-acceptable otic therapeutic agent composition has less than about4 EU/g of unit or Product. In additional embodiments, theauris-acceptable otic therapeutic agent composition has less than about3 EU/g of unit or Product. In some embodiments, the auris-acceptableotic therapeutic agent composition has less than about 5 EU/mg of unitor Product. In other embodiments, the auris-acceptable otic therapeuticagent composition has less than about 4 EU/mg of unit or Product. Inadditional embodiments, the auris-acceptable otic therapeutic agentcomposition has less than about 3 EU/mg of unit or Product. In certainembodiments, otic compositions described herein contain from about 1 toabout 5 EU/mL of composition. In certain embodiments, otic compositionsdescribed herein contain from about 2 to about 5 EU/mL of composition,from about 3 to about 5 EU/mL of composition, or from about 4 to about 5EU/mL of composition.

In certain embodiments, otic compositions or devices described hereincontain lower endotoxin levels (e.g. <0.5 EU/mL of composition) whencompared to conventionally acceptable endotoxin levels (e.g., 0.5 EU/mLof composition). In some embodiments, the auris-acceptable otictherapeutic agent composition or device has less than about 0.5 EU/mL ofcomposition. In other embodiments, the auris-acceptable otic therapeuticagent composition has less than about 0.4 EU/mL of composition. Inadditional embodiments, the auris-acceptable otic therapeutic agentcomposition has less than about 0.2 EU/mL of composition.

Pyrogen detection, by way of example only, is performed by severalmethods. Suitable tests for sterility include tests described in UnitedStates Pharmacopoeia (USP) <71> Sterility Tests (23rd edition, 1995).The rabbit pyrogen test and the Limulus amebocyte lysate test are bothspecified in the United States Pharmacopeia Chapters <85> and <151>(USP23/NF 18, Biological Tests, The United States PharmacopeialConvention, Rockville, Md., 1995). Alternative pyrogen assays have beendeveloped based upon the monocyte activation-cytokine assay. Uniformcell lines suitable for quality control applications have been developedand have demonstrated the ability to detect pyrogenicity in samples thathave passed the rabbit pyrogen test and the Limulus amebocyte lysatetest (Taktak et al, J. Pharm. Pharmacol. (1990), 43:578-82). In anadditional embodiment, the auris-acceptable otic therapeutic agentcomposition is subject to depyrogenation. In a further embodiment, theprocess for the manufacture of the auris-acceptable otic therapeuticagent composition comprises testing the composition for pyrogenicity. Incertain embodiments, the compositions described herein are substantiallyfree of pyrogens.

pH and Practical Osmolarity

In some embodiments, an otic composition or device disclosed herein isformulated to provide an ionic balance that is compatible with inner earfluids (e.g., endolymph and/or perilymph).

In certain instances, the ionic composition of the endolymph andperilymph regulate the electrochemical impulses of hair cells and thushearing. In certain instances, changes in the conduction ofelectrochemical impulses along otic hair cells results in hearing loss.In certain instances, changes in the ionic balance of the endolymph orperilymph results in complete hearing loss. In certain instances,changes in the ionic balance of the endolymph or perilymph results inpartial hearing loss. In certain instances, changes in the ionic balanceof the endolymph or perilymph results in permanent hearing loss. Incertain instances, changes in the ionic balance of the endolymph orperilymph results in temporary hearing loss.

In some embodiments, a composition or device disclosed herein isformulated in order to not disrupt the ionic balance of the endolymph.In some embodiments, a composition or device disclosed herein has anionic balance that is the same as or substantially the same as theendolymph. In some embodiments, a composition or device disclosed hereindoes not does not disrupt the ionic balance of the endolymph so as toresult in partial or complete hearing loss. In some embodiments, acomposition or device disclosed herein does not does not disrupt theionic balance of the endolymph so as to result in temporary or permanenthearing loss.

In some embodiments, a composition or device disclosed herein does notsubstantially disrupt the ionic balance of the perilymph. In someembodiments, a composition or device disclosed herein has an ionicbalance that is the same as or substantially the same as the perilymph.In some embodiments, a composition or device disclosed herein does notresult in partial or complete hearing loss as the composition or devicedoes not disrupt the ionic balance of the perilymph. In someembodiments, a composition or device disclosed herein does not result intemporary or permanent hearing loss as the composition or device doesnot disrupt the ionic balance of the perilymph.

As used herein, “practical osmolarity/osmolality” or “deliverableosmolarity/osmolality” means the osmolarity/osmolality of a compositionor device as determined by measuring the osmolarity/osmolality of theactive agent and all excipients except the gelling and/or the thickeningagent (e.g., polyoxyethylene-polyooxypropylene copolymers,carboxymethylcellulose or the like). The practical osmolarity of acomposition or device disclosed herein is measured by a suitable method,e.g., a freezing point depression method as described in Viegas et. al.,Int. J. Pharm., 1998, 160, 157-162. In some instances, the practicalosmolarity of a composition or device disclosed herein is measured byvapor pressure osmometry (e.g., vapor pressure depression method) thatallows for determination of the osmolarity of a composition or device athigher temperatures. In some instances, vapor pressure depression methodallows for determination of the osmolarity of a composition or devicecomprising a gelling agent (e.g., a thermoreversible polymer) at ahigher temperature wherein the gelling agent is in the form of a gel.

In some embodiments, the osmolarity at a target site of action (e.g.,the perilymph) is about the same as the delivered osmolarity (i.e.,osmolarity of materials that cross or penetrate the round windowmembrane) of a composition or device described herein. In someembodiments, a composition or device described herein has a deliverableosmolarity of about 150 mOsm/L to about 500 mOsm/L, about 250 mOsm/L toabout 500 mOsm/L, about 250 mOsm/L to about 350 mOsm/L, about 280 mOsm/Lto about 370 mOsm/L or about 250 mOsm/L to about 320 mOsm/L.

The practical osmolality of an otic composition or device disclosedherein is from about 100 mOsm/kg to about 1000 mOsm/kg, from about 200mOsm/kg to about 800 mOsm/kg, from about 250 mOsm/kg to about 500mOsm/kg, or from about 250 mOsm/kg to about 320 mOsm/kg, or from about250 mOsm/kg to about 350 mOsm/kg or from about 280 mOsm/kg to about 320mOsm/kg. In some embodiments, a composition or device described hereinhas a practical osmolarity of about 100 mOsm/L to about 1000 mOsm/L,about 200 mOsm/L to about 800 mOsm/L, about 250 mOsm/L to about 500mOsm/L, about 250 mOsm/L to about 350 mOsm/L, about 250 mOsm/L to about320 mOsm/L, or about 280 mOsm/L to about 320 mOsm/L.

The main cation present in the endolymph is potassium. In addition theendolymph has a high concentration of positively charged amino acids.The main cation present in the perilymph is sodium. In certaininstances, the ionic composition of the endolymph and perilymph regulatethe electrochemical impulses of hair cells. In certain instances, anychange in the ionic balance of the endolymph or perilymph results in aloss of hearing due to changes in the conduction of electrochemicalimpulses along otic hair cells. In some embodiments, a compositiondisclosed herein does not disrupt the ionic balance of the perilymph. Insome embodiments, a composition disclosed herein has an ionic balancethat is the same as or substantially the same as the perilymph. In someembodiments, a composition disclosed herein does not disrupt the ionicbalance of the endolymph. In some embodiments, a composition disclosedherein has an ionic balance that is the same as or substantially thesame as the endolymph. In some embodiments, an otic compositiondescribed herein is formulated to provide an ionic balance that iscompatible with inner ear fluids (e.g., endolymph and/or perilymph).

The endolymph and the perilymph have a pH that is close to thephysiological pH of blood. The endolymph has a pH range of about7.2-7.9; the perilymph has a pH range of about 7.2-7.4. The in situ pHof the proximal endolymph is about 7.4 while the pH of distal endolymphis about 7.9.

In some embodiments, the pH of a composition described herein isadjusted (e.g., by use of a buffer) to an endolymph-compatible pH rangeof about 5.5 to 9.0. In specific embodiments, the pH of a compositiondescribed herein is adjusted to a perilymph-suitable pH range of about5.5 to about 9.0.

In some embodiments, the pH of a composition described herein isadjusted to a perilymph-suitable range of about 5.5 to about 8.0, about6 to about 8.0 or about 6.6 to about 8.0. In some embodiments, the pH ofa composition described herein is adjusted to a perilymph-suitable pHrange of about 7.0-7.6.

In some embodiments, useful compositions also include one or more pHadjusting agents or buffering agents. Suitable pH adjusting agents orbuffers include, but are not limited to acetate, bicarbonate, ammoniumchloride, citrate, phosphate, pharmaceutically acceptable salts thereofand combinations or mixtures thereof.

In one embodiment, when one or more buffers are utilized in thecompositions of the present disclosure, they are combined (e.g., with apharmaceutically acceptable vehicle) and are present in the finalcomposition (e.g., in an amount ranging from about 0.1% to about 20%,from about 0.5% to about 10%). In certain embodiments of the presentdisclosure, the amount of buffer included in the gel compositions are anamount such that the pH of the gel composition does not interfere withthe body's natural buffering system.

In one embodiment, diluents are also used to stabilize compounds becausethey can provide a more stable environment. Salts dissolved in bufferedsolutions (that also can provide pH control or maintenance) are utilizedas diluents in the art, including, but not limited to a phosphatebuffered saline solution.

In some embodiments, any gel composition described herein has a pH thatallows for sterilization (e.g., by filtration or aseptic mixing or heattreatment and/or autoclaving (e.g., terminal sterilization)) of a gelcomposition without degradation of the pharmaceutical agent or thepolymers comprising the gel. In order to reduce hydrolysis and/ordegradation of the otic agent and/or the gel polymer duringsterilization, the buffer pH is designed to maintain pH of thecomposition in the 7-8 range during the process of sterilization (e.g.,high temperature autoclaving).

In specific embodiments, any gel composition described herein has a pHthat allows for terminal sterilization (e.g., by heat treatment and/orautoclaving) of a gel composition without degradation of thepharmaceutical agent or the polymers comprising the gel. For example, inorder to reduce hydrolysis and/or degradation of the otic agent and/orthe gel polymer during autoclaving, the buffer pH is designed tomaintain pH of the composition in the 7-8 range at elevatedtemperatures. Any appropriate buffer is used depending on the otic agentused in the composition. In some instances, since pK_(a) of TRISdecreases as temperature increases at approximately −0.03/° C. andpK_(a) of PBS increases as temperature increases at approximately0.003/° C., autoclaving at 250° F. (121° C.) results in a significantdownward pH shift (i.e. more acidic) in the TRIS buffer whereas arelatively much less upward pH shift in the PBS buffer and thereforemuch increased hydrolysis and/or degradation of an otic agent in TRISthan in PBS. Degradation of an otic agent is reduced by the use of anappropriate combination of a buffer and polymeric additives (e.g. P407,CMC) as described herein.

In some embodiments, a composition pH of between about 5.0 and about9.0, between about 5.5 and about 8.5, between about 6.0 and about 7.6,between about 7 and about 7.8, between about 7.0 and about 7.6, betweenabout 7.2 and 7.6, or between about 7.2 and about 7.4 is suitable forsterilization (e.g., by filtration or aseptic mixing or heat treatmentand/or autoclaving (e.g., terminal sterilization)) of auris compositionsdescribed herein. In specific embodiments a composition pH of about 6.0,about 6.5, about 7.0, about 7.1, about 7.2, about 7.3, about 7.4, about7.5, or about 7.6 is suitable for sterilization (e.g., by filtration oraseptic mixing or heat treatment and/or autoclaving (e.g., terminalsterilization)) of any composition described herein.

In some embodiments, the compositions have a pH as described herein, andinclude a thickening agent (e.g., a viscosity enhancing agent) such as,by way of non-limiting example, a cellulose based thickening agentdescribed herein. In some instances, the addition of a secondary polymer(e.g., a thickening agent) and a pH of composition as described herein,allows for sterilization of a composition described herein without anysubstantial degradation of the otic agent and/or the polymer componentsin the otic composition. In some embodiments, the ratio of athermoreversible poloxamer to a thickening agent in a composition thathas a pH as described herein, is about 40:1, about 35:1, about 30:1,about 25:1, about 20:1, about 15:1 about 10:1, or about 5:1. Forexample, in certain embodiments, a sustained and/or extended releasecomposition described herein comprises a combination of poloxamer 407(pluronic F127) and carboxymethylcellulose (CMC) in a ratio of about40:1, about 35:1, about 30:1, about 25:1, about 20:1, about 15:1, about10:1 or about 5:1.

In some embodiments, the amount of thermoreversible polymer in anycomposition described herein is about 10%, about 15%, about 20%, about25%, about 30%, about 35% or about 40% of the total weight of thecomposition. In some embodiments, the amount of thermoreversible polymerin any composition described herein is about 10%, about 11%, about 12%,about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about19%, about 20%, about 21%, about 22%, about 23%, about 24% or about 25%of the total weight of the composition. In some embodiments, the amountof thermoreversible polymer (e.g., pluronic F127) in any compositiondescribed herein is about 7.5% of the total weight of the composition.In some embodiments, the amount of thermoreversible polymer (e.g.,pluronic F127) in any composition described herein is about 10% of thetotal weight of the composition.

In some embodiments, the amount of thermoreversible polymer (e.g.,pluronic F127) in any composition described herein is about 11% of thetotal weight of the composition. In some embodiments, the amount ofthermoreversible polymer (e.g., pluronic F127) in any compositiondescribed herein is about 12% of the total weight of the composition. Insome embodiments, the amount of thermoreversible polymer (e.g., pluronicF127) in any composition described herein is about 13% of the totalweight of the composition. In some embodiments, the amount ofthermoreversible polymer (e.g., pluronic F127) in any compositiondescribed herein is about 14% of the total weight of the composition. Insome embodiments, the amount of thermoreversible polymer (e.g., pluronicF127) in any composition described herein is about 15% of the totalweight of the composition. In some embodiments, the amount ofthermoreversible polymer (e.g., pluronic F127) in any compositiondescribed herein is about 16% of the total weight of the composition. Insome embodiments, the amount of thermoreversible polymer (e.g., pluronicF127) in any composition described herein is about 17% of the totalweight of the composition. In some embodiments, the amount ofthermoreversible polymer (e.g., pluronic F127) in any compositiondescribed herein is about 18% of the total weight of the composition. Insome embodiments, the amount of thermoreversible polymer (e.g., pluronicF127) in any composition described herein is about 19% of the totalweight of the composition. In some embodiments, the amount ofthermoreversible polymer (e.g., pluronic F127) in any compositiondescribed herein is about 20% of the total weight of the composition. Insome embodiments, the amount of thermoreversible polymer (e.g., pluronicF127) in any composition described herein is about 21% of the totalweight of the composition. In some embodiments, the amount ofthermoreversible polymer (e.g., pluronic F127) in any compositiondescribed herein is about 23% of the total weight of the composition. Insome embodiments, the amount of thermoreversible polymer (e.g., pluronicF127) in any composition described herein is about 25% of the totalweight of the composition.

In some embodiments, the amount of thickening agent (e.g., a gellingagent) in any composition described herein is about 1%, about 5%, about10%, or about 15% of the total weight of the composition. In someembodiments, the amount of thickening agent (e.g., a gelling agent) inany composition described herein is about 0.5%, about 1%, about 1.5%,about 2%, about 2.5%, about 3%, about 3.5%, about 4%, about 4.5%, orabout 5% of the total weight of the composition.

In some embodiments, the pharmaceutical compositions described hereinare stable with respect to pH over a period of any of at least about 1day, at least about 2 days, at least about 3 days, at least about 4days, at least about 5 days, at least about 6 days, at least about 1week, at least about 2 weeks, at least about 3 weeks, at least about 4weeks, at least about 5 weeks, at least about 6 weeks, at least about 7weeks, at least about 8 weeks, at least about 1 month, at least about 2months, at least about 3 months, at least about 4 months, at least about5 months, or at least about 6 months. In other embodiments, thecompositions described herein are stable with respect to pH over aperiod of at least about 1 week. Also described herein are compositionsthat are stable with respect to pH over a period of at least about 1month.

Tonicity Agents

In general, the endolymph has a higher osmolality than the perilymph.For example, the endolymph has an osmolality of about 304 mOsm/kg H₂Owhile the perilymph has an osmolality of about 294 mOsm/kg H₂O. Incertain embodiments, tonicity agents are added to the compositionsdescribed herein in an amount as to provide a practical osmolality of anotic composition of about 100 mOsm/kg to about 1000 mOsm/kg, from about200 mOsm/kg to about 800 mOsm/kg, from about 250 mOsm/kg to about 500mOsm/kg, or from about 250 mOsm/kg to about 350 mOsm/kg or from about280 mOsm/kg to about 320 mOsm/kg. In some embodiments, the compositionsdescribed herein have a practical osmolarity of about 100 mOsm/L toabout 1000 mOsm/L, about 200 mOsm/L to about 800 mOsm/L, about 250mOsm/L to about 500 mOsm/L, about 250 mOsm/L to about 350 mOsm/L, about280 mOsm/L to about 320 mOsm/L or about 250 mOsm/L to about 320 mOsm/L.

In some embodiments, the deliverable osmolarity of any compositiondescribed herein is designed to be isotonic with the targeted oticstructure (e.g., endolymph, perilymph or the like). In specificembodiments, auris compositions described herein are formulated toprovide a delivered perilymph-suitable osmolarity at the target site ofaction of about 250 to about 320 mOsm/L (osmolality of about 250 toabout 320 mOsm/kg H₂O); and preferably about 270 to about 320 mOsm/L(osmolality of about 270 to about 320 mOsm/kg H₂O). In specificembodiments, the deliverable osmolarity/osmolality of the compositions(i.e., the osmolarity/osmolality of the composition in the absence ofgelling or thickening agents (e.g., thermoreversible gel polymers)) isadjusted, for example, by the use of appropriate salt concentrations(e.g., concentration of potassium or sodium salts) or the use oftonicity agents that renders the compositions endolymph-compatibleand/or perilymph-compatible (i.e. isotonic with the endolymph and/orperilymph) upon delivery at the target site. The osmolarity of acomposition comprising a thermoreversible gel polymer is an unreliablemeasure due to the association of varying amounts of water with themonomeric units of the polymer. The practical osmolarity of acomposition is a reliable measure and is measured by any suitable method(e.g., freezing point depression method, vapor depression method). Insome instances, the compositions described herein provide a deliverableosmolarity (e.g., at a target site (e.g., perilymph)) that causesminimal disturbance to the environment of the inner ear and causesminimum discomfort (e.g., vertigo and/or nausea) to a mammal uponadministration.

In some embodiments, any composition described herein is isotonic withthe perilymph and/or endolymph. Isotonic compositions are provided bythe addition of a tonicity agent. Suitable tonicity agents include, butare not limited to any pharmaceutically acceptable sugar, salt or anycombinations or mixtures thereof, such as, but not limited to dextrose,glycerin, mannitol, sorbitol, sodium chloride, and other electrolytes.

Useful auris compositions include one or more salts in an amountrequired to bring osmolality of the composition into an acceptablerange. Such salts include those having sodium, potassium or ammoniumcations and chloride, citrate, ascorbate, borate, phosphate,bicarbonate, sulfate, thiosulfate or bisulfite anions; suitable saltsinclude sodium chloride, potassium chloride, sodium thiosulfate, sodiumbisulfite and ammonium sulfate.

In some embodiments, the compositions described herein have a pH and/orpractical osmolarity as described herein, and have a concentration ofactive pharmaceutical ingredient between about 1 μM and about 10 μM,between about 1 mM and about 100 mM, between about 0.1 mM and about 100mM, between about 0.1 mM and about 100 nM. In some embodiments, thecompositions described herein have a pH and/or practical osmolarity asdescribed herein, and have a concentration of active pharmaceuticalingredient between about 0.01%-about 20%, between about 0.01%-about 10%,between about 0.01%-about 7.5%, between about 0.01%-6%, between about0.01-5%, between about 0.1-about 10%, or between about 0.1-about 6% ofthe active ingredient by weight of the composition. In some embodiments,the compositions described herein have a pH and/or practical osmolarityas described herein, and have a concentration of active pharmaceuticalingredient between about 0.1 and about 70 mg, between about 1 mg andabout 70 mg/mL, between about 1 mg and about 50 mg/mL, between about 1mg/mL and about 20 mg/mL, between about 1 mg/mL to about 10 mg/mL,between about 1 mg/mL to about 5 mg/mL, or between about 0.5 mg/mL toabout 5 mg/mL of the active agent by volume of the composition. In someembodiments, the compositions described herein have a pH and/orpractical osmolarity as described herein, and have a concentration ofactive pharmaceutical ingredient between about 1 μg/mL and about 500μg/mL, between about 1 μg/mL and about 250 μg/mL, between about 1 μg andabout 100 μg/mL, between about 1 μg/mL and about 50 μg/mL, or betweenabout 1 μg/mL and about 20 μg/mL of the active agent by volume of thecomposition.

Particle Size

Size reduction is used to increase surface area and/or modulatecomposition dissolution properties. It is also used to maintain aconsistent average particle size distribution (PSD) (e.g.,micrometer-sized particles, nanometer-sized particles or the like) forany composition described herein. In some embodiments, any compositiondescribed herein is multiparticulate (i.e., comprises a plurality ofparticle sizes (e.g., micronized particles, nano-sized particles,non-sized particles, colloidal particles)).

In some embodiments, any composition described herein comprises one ormore multiparticulate (e.g., micronized) therapeutic agents.Micronization is a process of reducing the average diameter of particlesof a solid material. Micronized particles are from aboutmicrometer-sized in diameter to about nanometer-sized in diameter. Insome embodiments, the average diameter of particles in a micronizedsolid is from about 0.5 μm to about 500 μm. In some embodiments, theaverage diameter of particles in a micronized solid is from about 1 μmto about 200 μm. In some embodiments, the average diameter of particlesin a micronized solid is from about 2 μm to about 100 μm. In someembodiments, the average diameter of particles in a micronized solid isfrom about 3 μm to about 50 μm. In some embodiments, a particulatemicronized solid comprises particle sizes of less than about 5 microns,less than about 20 microns and/or less than about 100 microns. In someembodiments, the use of particulates (e.g., micronized particles) of anotic structure modulating agent or innate immune system modulating agentallows for extended and/or sustained release of the otic structuremodulating agent or innate immune system modulating agent from anycomposition described herein compared to a composition comprisingnon-multiparticulate (e.g., non-micronized) otic structure modulatingagent or innate immune system modulating agent. In some instances,compositions containing multiparticulate (e.g. micronized) oticstructure modulating agent or innate immune system modulating agent areejected from a 1 mL syringe adapted with a 27G needle without anyplugging or clogging.

In some instances, any particle in any composition described herein is acoated particle (e.g., a coated micronized particle, nano-particle)and/or a microsphere and/or a liposomal particle. Particle sizereduction techniques include, by way of example, grinding, milling(e.g., air-attrition milling (jet milling), ball milling), coacervation,complex coacervation, high pressure homogenization, spray drying and/orsupercritical fluid crystallization. In some instances, particles aresized by mechanical impact (e.g., by hammer mills, ball mill and/or pinmills). In some instances, particles are sized via fluid energy (e.g.,by spiral jet mills, loop jet mills, and/or fluidized bed jet mills). Insome embodiments, compositions described herein comprise crystallineparticles and/or isotropic particles. In some embodiments, compositionsdescribed herein comprise amorphous particles and/or anisotropicparticles. In some embodiments, compositions described herein comprisetherapeutic agent particles wherein the therapeutic agent is a neutralmolecule, a free acid, a free base, or a salt, or a prodrug of atherapeutic agent, or any combination thereof.

In some embodiments, a composition described herein comprises an oticstructure modulating agent or innate immune system modulating agentswherein the otic structure modulating agent or innate immune systemmodulating agent comprises nanoparticulates. In some embodiments, acomposition described herein comprises otic structure modulating agentor innate immune system modulating agent beads (e.g., tacrolimus beads)that are optionally coated with controlled-release excipients. In someembodiments, a composition described herein comprises an otic structuremodulating agent or innate immune system modulating agent that isgranulated and/or reduced in size and coated with controlled-releaseexcipients; the granulated coated otic structure modulating agent orinnate immune system modulating agent particulates are then optionallymicronized and/or formulated in any of the compositions describedherein.

In some instances, a combination of an otic structure modulating agentor innate immune system modulating agent as a neutral molecule, a freeacid, a free base and a salt of the otic structure modulating agent orinnate immune system modulating agent is used to prepare pulsed releaseotic agent compositions using the procedures described herein. In somecompositions, a combination of a micronized otic structure modulatingagent or innate immune system modulating agent (and/or salt or prodrugthereof) and coated particles (e.g., nanoparticles, liposomes,microspheres) is used to prepare pulsed release otic agent compositionsusing any procedure described herein. Alternatively, a pulsed releaseprofile is achieved by solubilizing up to 20% of the delivered dose ofthe otic structure modulating agent or innate immune system modulatingagent (e.g., micronized otic structure modulating agent or innate immunesystem modulating agent, a neutral molecule, free base, free acid orsalt or prodrug thereof, multiparticulate otic structure modulatingagent or innate immune system modulating agent, a neutral molecule, afree base, free acid or salt or prodrug thereof) with the aid ofcyclodextrins, surfactants (e.g., poloxamers (407, 338, 188), tween (80,60, 20, 81), PEG-hydrogenated castor oil, cosolvents likeN-methyl-2-Pyrrolidone or the like and preparing pulsed releasecompositions using any procedure described herein.

In specific embodiments, any auris-compatible composition describedherein comprises one or more micronized pharmaceutical agents (e.g.,otic structure modulating agent or innate immune system modulatingagents). In some of such embodiments, a micronized pharmaceutical agentcomprises micronized particles, coated (e.g., with an extended releasecoat) micronized particles, or a combination thereof. In some of suchembodiments, a micronized pharmaceutical agent comprising micronizedparticles, coated micronized particles, or a combination thereof,comprises an otic structure modulating agent or innate immune systemmodulating agent as a neutral molecule, a free acid, a free base, asalt, a prodrug or any combination thereof. In certain embodiments, apharmaceutical composition described herein comprises an otic structuremodulating agent or innate immune system modulating agent as amicronized powder.

The multiparticulates and/or micronized otic structure modulating agentor innate immune system modulating agents described herein are deliveredto an auris structure (e.g., inner ear) by means of any type of matrixincluding solid, liquid or gel matrices. In some embodiments, themultiparticulates and/or micronized otic structure modulating agent orinnate immune system modulating agents described herein are delivered toan auris structure (e.g., inner ear) by means of any type of matrixincluding solid, liquid or gel matrices via intratympanic injection.

Pharmaceutical Compositions

Provided herein are pharmaceutical compositions or devices that includean otic structure modulating agent or innate immune system modulatingagent and a pharmaceutically acceptable diluent(s), excipient(s), orcarrier(s). In some embodiments, the pharmaceutical compositions includeother medicinal or pharmaceutical agents, carriers, adjuvants, such aspreserving, stabilizing, wetting or emulsifying agents, solutionpromoters, salts for regulating the osmotic pressure, and/or buffers. Inother embodiments, the pharmaceutical compositions also contain othertherapeutic substances.

Some pharmaceutical excipients, diluents or carriers are potentiallyototoxic. For example, benzalkonium chloride, a common preservative, isototoxic and therefore potentially harmful if introduced into thevestibular or cochlear structures. In formulating a controlled-releaseotic structure modulating composition, it is advised to avoid or combinethe appropriate excipients, diluents or carriers to lessen or eliminatepotential ototoxic components from the composition, or to decrease theamount of such excipients, diluents or carriers. Optionally, acontrolled-release otic structure modulating composition includesotoprotective agents, such as antioxidants, alpha lipoic acid, calcium,fosfomycin or iron chelators, to counteract potential ototoxic effectsthat may arise from the use of specific therapeutic agents orexcipients, diluents or carriers.

In some embodiments, the compositions or devices described hereininclude a dye to help enhance the visualization of the gel when applied.In some embodiments, dyes that are compatible with the auris-acceptablecompositions or devices described herein include Evans blue (e.g., 0.5%of the total weight of an otic composition), Methylene blue (e.g., 1% ofthe total weight of an otic composition), Isosulfan blue (e.g., 1% ofthe total weight of an otic composition), Trypan blue (e.g., 0.15% ofthe total weight of an otic composition), and/or indocyanine green(e.g., 25 mg/vial). Other common dyes, e.g., FD&C red 40, FD&C red 3,FD&C yellow 5, FD&C yellow 6, FD&C blue 1, FD&C blue2, FD&C green 3,fluorescence dyes (e.g., Fluorescein isothiocyanate, rhodamine, AlexaFluors, DyLight Fluors) and/or dyes that are visualizable in conjunctionwith non-invasive imaging techniques such as MRI, CAT scans, PET scansor the like. Gadolinium-based MRI dyes, iodine-base dyes, barium-baseddyes or the like are also contemplated for use with any otic compositiondescribed herein. Other dyes that are compatible with any compositiondescribed herein are listed in the Sigma-Aldrich catalog under dyes(that is included herein by reference for such disclosure).

Any pharmaceutical composition or device described herein isadministered by locating the composition or device in contact with thecrista fenestrae cochlea, the round window, the tympanic cavity, thetympanic membrane, the auris media or the auris externa.

In one specific embodiment of the auris-acceptable controlled-releaseotic structure modulating agent or innate immune system modulating agentpharmaceutical compositions described herein, the otic structuremodulating agent or innate immune system modulating agent is provided ina gel matrix, also referred to herein as “auris acceptable gelcompositions,” “auris interna-acceptable gel compositions,” “aurismedia-acceptable gel compositions,” “auris externa-acceptable gelcompositions”, “auris gel compositions” or variations thereof. All ofthe components of the gel composition must be compatible with thetargeted auris structure. Further, the gel compositions providecontrolled-release of the otic structure modulating agent or innateimmune system modulating agent to the desired site within the targetedauris structure; in some embodiments, the gel composition also has animmediate or rapid release component for delivery of the otic structuremodulating agent or innate immune system modulating agent to the desiredtarget site. In other embodiments, the gel composition has a sustainedrelease component for delivery of the otic structure modulating agent orinnate immune system modulating agent. In some embodiments, the gelcomposition comprises a multiparticulate (e.g., micronized) oticstructure modulating agent or innate immune system modulating agent. Insome embodiments, the auris gel compositions are biodegradable. In otherembodiments, the auris gel compositions include a mucoadhesive excipientto allow adhesion to the external mucous layer of the round windowmembrane. In yet other embodiments, the auris gel compositions include apenetration enhancer excipient; in further embodiments, the auris gelcomposition contains a viscosity enhancing agent sufficient to provide aviscosity of between about 500 and 1,000,000 centipoise, between about750 and 1,000,000 centipoise; between about 1000 and 1,000,000centipoise; between about 1000 and 400,000 centipoise; between about2000 and 100,000 centipoise; between about 3000 and 50,000 centipoise;between about 4000 and 25,000 centipoise; between about 5000 and 20,000centipoise; or between about 6000 and 15,000 centipoise. In someembodiments, the auris gel composition contains a viscosity enhancingagent sufficient to provide a viscosity of between about 50,0000 and1,000,000 centipoise.

In other embodiments, the auris interna pharmaceutical compositionsdescribed herein further provide an auris-acceptable hydrogel; in yetother embodiments, the auris pharmaceutical compositions provide anauris-acceptable microsphere or microparticle; in still otherembodiments, the auris pharmaceutical compositions provide anauris-acceptable liposome. In some embodiments, the auris pharmaceuticalcompositions provide an auris-acceptable foam; in yet other embodiments,the auris pharmaceutical compositions provide an auris-acceptable paint;in still further embodiments, the auris pharmaceutical compositionsprovide an auris-acceptable in situ forming spongy material. In someembodiments, the auris pharmaceutical compositions provide anauris-acceptable solvent release gel. In some embodiments, the aurispharmaceutical compositions provide an actinic radiation curable gel.Further embodiments include a thermoreversible gel in the aurispharmaceutical composition, such that upon preparation of the gel atroom temperature or below, the composition is a fluid, but uponapplication of the gel into or near the auris interna and/or auris mediatarget site, including the tympanic cavity, round window membrane or thecrista fenestrae cochleae, the auris-pharmaceutical composition stiffensor hardens into a gel-like substance.

In further or alternative embodiments, the auris gel compositions arecapable of being administered on or near the round window membrane viaintratympanic injection. In other embodiments, the auris gelcompositions are administered on or near the round window or the cristafenestrae cochleae through entry via a post-auricular incision andsurgical manipulation into or near the round window or the cristafenestrae cochleae area. Alternatively, the auris gel composition isapplied via syringe and needle, wherein the needle is inserted throughthe tympanic membrane and guided to the area of the round window orcrista fenestrae cochleae. The auris gel compositions are then depositedon or near the round window or crista fenestrae cochleae for localizedtreatment. In other embodiments, the auris gel compositions are appliedvia microcatheters implanted into the patient, and in yet furtherembodiments the compositions are administered via a pump device onto ornear the round window membrane. In still further embodiments, the aurisgel compositions are applied at or near the round window membrane via amicroinjection device. In yet other embodiments, the auris gelcompositions are applied in the tympanic cavity. In some embodiments,the auris gel compositions are applied on the tympanic membrane. Instill other embodiments, the auris gel compositions are applied onto orin the auditory canal.

In further specific embodiments, any pharmaceutical composition ordevice described herein comprises a multiparticulate otic structuremodulating agent or innate immune system modulating agent in a liquidmatrix (e.g., a liquid composition for intratympanic injection, or oticdrops). In certain embodiments, any pharmaceutical composition describedherein comprises a multiparticulate otic structure modulating agent orinnate immune system modulating agent in a solid matrix.

Controlled-Release Compositions

In general, controlled-release drug compositions impart control over therelease of drug with respect to site of release and time of releasewithin the body. As discussed herein, controlled-release refers toimmediate release, delayed release, sustained release, extended release,variable release, pulsatile release and bi-modal release. Manyadvantages are offered by controlled-release. First, controlled-releaseof a pharmaceutical agent allows less frequent dosing and thus minimizesrepeated treatment. Second, controlled-release treatment results in moreefficient drug utilization and less of the compound remains as aresidue. Third, controlled-release offers the possibility of localizeddrug delivery by placement of a delivery device or composition at thesite of disease. Still further, controlled-release offers theopportunity to administer and release two or more different drugs, eachhaving a unique release profile, or to release the same drug atdifferent rates or for different durations, by means of a single dosageunit.

Accordingly, one aspect of the embodiments disclosed herein is toprovide a controlled-release otic structure modulating auris-acceptablecomposition or. The controlled-release aspect of the compositions and/orcompositions and/or devices disclosed herein is imparted through avariety of agents, including but not limited to excipients, agents ormaterials that are acceptable for use in the auris interna or other oticstructure. By way of example only, such excipients, agents or materialsinclude an auris-acceptable polymer, an auris-acceptable viscosityenhancing agent, an auris-acceptable gel, an auris-acceptable paint, anauris-acceptable foam, an auris-acceptable xerogel, an auris-acceptablemicrosphere or microparticle, an auris-acceptable hydrogel, anauris-acceptable in situ forming spongy material, an auris-acceptableactinic radiation curable gel, an auris-acceptable solvent release gel,an auris-acceptable liposome, an auris-acceptable nanocapsule ornanosphere, an auris-acceptable thermoreversible gel, or combinationsthereof.

Auris-Acceptable Gels

Gels, sometimes referred to as jellies, have been defined in variousways. For example, the United States Pharmacopoeia defines gels assemisolid systems consisting of either suspensions made up of smallinorganic particles or large organic molecules interpenetrated by aliquid. Gels include a single-phase or a two-phase system. Asingle-phase gel consists of organic macromolecules distributeduniformly throughout a liquid in such a manner that no apparentboundaries exist between the dispersed macromolecules and the liquid.Some single-phase gels are prepared from synthetic macromolecules (e.g.,carbomer) or from natural gums, (e.g., tragacanth). In some embodiments,single-phase gels are generally aqueous, but will also be made usingalcohols and oils. Two-phase gels consist of a network of small discreteparticles.

Gels can also be classified as being hydrophobic or hydrophilic. Incertain embodiments, the base of a hydrophobic gel consists of a liquidparaffin with polyethylene or fatty oils gelled with colloidal silica,or aluminum or zinc soaps. In contrast, the base of hydrophobic gelsusually consists of water, glycerol, or propylene glycol gelled with asuitable gelling agent (e.g., tragacanth, starch, cellulose derivatives,carboxyvinylpolymers, and magnesium-aluminum silicates). In certainembodiments, the rheology of the compositions or devices disclosedherein is pseudo plastic, plastic, thixotropic, or dilatant.

In one embodiment the enhanced viscosity auris-acceptable compositiondescribed herein is not a liquid at room temperature. In certainembodiments, the enhanced viscosity composition is characterized by aphase transition between room temperature and body temperature(including an individual with a serious fever, e.g., up to about 42°C.). In some embodiments, the phase transition occurs at 1° C. belowbody temperature, at 2° C. below body temperature, at 3° C. below bodytemperature, at 4° C. below body temperature, at 6° C. below bodytemperature, at 8° C. below body temperature, or at 10° C. below bodytemperature. In some embodiments, the phase transition occurs at about15° C. below body temperature, at about 20° C. below body temperature orat about 25° C. below body temperature. In specific embodiments, thegelation temperature (Tgel) of a composition described herein is about20° C., about 25° C., or about 30° C. In certain embodiments, thegelation temperature (Tgel) of a composition described herein is about35° C., or about 40° C. In one embodiment, administration of anycomposition described herein at about body temperature reduces orinhibits vertigo associated with intratympanic administration of oticcompositions. Included within the definition of body temperature is thebody temperature of a healthy individual, or an unhealthy individual,including an individual with a fever (up to ˜42° C.). In someembodiments, the pharmaceutical compositions or devices described hereinare liquids at about room temperature and are administered at or aboutroom temperature, reducing or ameliorating side effects such as, forexample, vertigo.

Polymers composed of polyoxypropylene and polyoxyethylene formthermoreversible gels when incorporated into aqueous solutions. Thesepolymers have the ability to change from the liquid state to the gelstate at temperatures close to body temperature, therefore allowinguseful compositions that are applied to the targeted auris structure(s).The liquid state-to-gel state phase transition is dependent on thepolymer concentration and the ingredients in the solution.

Poloxamer 407 (PF-127) is a nonionic surfactant composed ofpolyoxyethylene-polyoxypropylene copolymers. Other poloxamers include188 (F-68 grade), 237 (F-87 grade), 338 (F-108 grade). Aqueous solutionsof poloxamers are stable in the presence of acids, alkalis, and metalions. PF-127 is a commercially availablepolyoxyethylene-polyoxypropylene triblock copolymer of general formulaE106 P70 E106, with an average molar mass of 13,000. The polymer can befurther purified by suitable methods that will enhance gelationproperties of the polymer. It contains approximately 70% ethylene oxide,which accounts for its hydrophilicity. It is one of the series ofpoloxamer ABA block copolymers, whose members share the chemical formulashown below.

PF-127 is of particular interest since concentrated solutions (>20% w/w)of the copolymer are transformed from low viscosity transparentsolutions to solid gels on heating to body temperature. This phenomenon,therefore, suggests that when placed in contact with the body, the gelpreparation will form a semi-solid structure and a sustained releasedepot. Furthermore, PF-127 has good solubilizing capacity, low toxicityand is, therefore, considered a good medium for drug delivery systems.

In an alternative embodiment, the thermogel is a PEG-PLGA-PEG triblockcopolymer (Jeong et al, Nature (1997), 388:860-2; Jeong et al, J.Control. Release (2000), 63:155-63; Jeong et al, Adv. Drug Delivery Rev.(2002), 54:37-51). The polymer exhibits sol-gel behavior over aconcentration of about 5% w/w to about 40% w/w. Depending on theproperties desired, the lactide/glycolide molar ratio in the PLGAcopolymer ranges from about 1:1 to about 20:1. The resulting copolymersare soluble in water and form a free-flowing liquid at room temperature,but form a hydrogel at body temperature. A commercially availablePEG-PLGA-PEG triblock copolymer is RESOMER RGP t50106 manufactured byBoehringer Ingelheim. This material is composed of a PGLA copolymer of50:50 poly(DL-lactide-co-glycolide) and is 10% w/w of PEG and has amolecular weight of about 6000.

ReGel® is a tradename of MacroMed Incorporated for a class of lowmolecular weight, biodegradable block copolymers having reverse thermalgelation properties as described in U.S. Pat. Nos. 6,004,573, 6,117,949,6,201,072, and 6,287,588. It also includes biodegradable polymeric drugcarriers disclosed in pending U.S. patent application Ser. Nos.09/906,041, 09/559,799 and 10/919,603. The biodegradable drug carriercomprises ABA-type or BAB-type triblock copolymers or mixtures thereof,wherein the A-blocks are relatively hydrophobic and comprisebiodegradable polyesters or poly(orthoester)s, and the B-blocks arerelatively hydrophilic and comprise polyethylene glycol (PEG), saidcopolymers having a hydrophobic content of between 50.1 to 83% by weightand a hydrophilic content of between 17 to 49.9% by weight, and anoverall block copolymer molecular weight of between 2000 and 8000Daltons. The drug carriers exhibit water solubility at temperaturesbelow normal mammalian body temperatures and undergo reversible thermalgelation to then exist as a gel at temperatures equal to physiologicalmammalian body temperatures. The biodegradable, hydrophobic A polymerblock comprises a polyester or poly(ortho ester), in that the polyesteris synthesized from monomers selected from the group consisting ofD,L-lactide, D-lactide, L-lactide, D,L-lactic acid, D-lactic acid,L-lactic acid, glycolide, glycolic acid, ε-caprolactone,ε-hydroxyhexanoic acid, γ-butyrolactone, γ-hydroxybutyric acid,β-valerolactone, β-hydroxyvaleric acid, hydroxybutyric acids, malicacid, and copolymers thereof and having an average molecular weight ofbetween about 600 and 3000 Daltons. The hydrophilic B-block segment ispreferably polyethylene glycol (PEG) having an average molecular weightof between about 500 and 2200 Daltons.

Additional biodegradable thermoplastic polyesters include AtriGel®(provided by Atrix Laboratories, Inc.) and/or those disclosed, e.g., inU.S. Pat. Nos. 5,324,519; 4,938,763; 5,702,716; 5,744,153; and5,990,194; wherein the suitable biodegradable thermoplastic polyester isdisclosed as a thermoplastic polymer. Examples of suitable biodegradablethermoplastic polyesters include polylactides, polyglycolides,polycaprolactones, copolymers thereof, terpolymers thereof, and anycombinations thereof. In some such embodiments, the suitablebiodegradable thermoplastic polyester is a polylactide, a polyglycolide,a copolymer thereof, a terpolymer thereof, or a combination thereof. Inone embodiment, the biodegradable thermoplastic polyester is 50/50poly(DL-lactide-co-glycolide) having a carboxy terminal group; ispresent in about 30 wt. % to about 40 wt. % of the composition; and hasan average molecular weight of about 23,000 to about 45,000.Alternatively, in another embodiment, the biodegradable thermoplasticpolyester is 75/25 poly (DL-lactide-co-glycolide) without a carboxyterminal group; is present in about 40 wt. % to about 50 wt. % of thecomposition; and has an average molecular weight of about 15,000 toabout 24,000. In further or alternative embodiments, the terminal groupsof the poly(DL-lactide-co-glycolide) are either hydroxyl, carboxyl, orester depending upon the method of polymerization. Polycondensation oflactic or glycolic acid provides a polymer with terminal hydroxyl andcarboxyl groups. Ring-opening polymerization of the cyclic lactide orglycolide monomers with water, lactic acid, or glycolic acid providespolymers with the same terminal groups. However, ring-opening of thecyclic monomers with a monofunctional alcohol such as methanol, ethanol,or 1-dodecanol provides a polymer with one hydroxyl group and one esterterminal groups. Ring-opening polymerization of the cyclic monomers witha diol such as 1,6-hexanediol or polyethylene glycol provides a polymerwith only hydroxyl terminal groups.

Since the polymer systems of thermoreversible gels dissolve morecompletely at reduced temperatures, methods of solubilization includeadding the required amount of polymer to the amount of water to be usedat reduced temperatures. Generally after wetting the polymer by shaking,the mixture is capped and placed in a cold chamber or in a thermostaticcontainer at about 0-10° C. in order to dissolve the polymer. Themixture is stirred or shaken to bring about a more rapid dissolution ofthe thermoreversible gel polymer. The otic structure modulating agent orinnate immune system modulating agent and various additives such asbuffers, salts, and preservatives are subsequently added and dissolved.In some instances the otic structure modulating agent or innate immunesystem modulating agent and/or other pharmaceutically active agent issuspended if it is insoluble in water. The pH is modulated by theaddition of appropriate buffering agents. round window membranemucoadhesive characteristics are optionally imparted to athermoreversible gel by incorporation of round window membranemucoadhesive carbomers, such as Carbopol® 934P, to the composition(Majithiya et al, AAPS PharmSciTech (2006), 7(3), p. E1; EP0551626, bothof that is incorporated herein by reference for such disclosure).

In one embodiment are auris-acceptable pharmaceutical gel compositionsthat do not require the use of an added viscosity enhancing agent. Suchgel compositions incorporate at least one pharmaceutically acceptablebuffer. In one aspect is a gel composition comprising an otic structuremodulating agent or innate immune system modulating agent and apharmaceutically acceptable buffer. In another embodiment, thepharmaceutically acceptable excipient or carrier is a gelling agent.

In other embodiments, useful otic structure modulating agent or innateimmune system modulating agent auris-acceptable pharmaceuticalcompositions also include one or more pH adjusting agents or bufferingagents to provide an endolymph or perilymph suitable pH. Suitable pHadjusting agents or buffers include, but are not limited to acetate,bicarbonate, ammonium chloride, citrate, phosphate, pharmaceuticallyacceptable salts thereof and combinations or mixtures thereof. Such pHadjusting agents and buffers are included in an amount required tomaintain pH of the composition between a pH of about 5 and about 9, inone embodiment a pH between about 6.5 to about 7.5, and in yet anotherembodiment at a pH of about 6.5, 6.6, 6.7, 6.8, 6.9, 7.0, 7.1, 7.2, 7.3,7.4, 7.5. In one embodiment, when one or more buffers are utilized inthe compositions of the present disclosure, they are combined, e.g.,with a pharmaceutically acceptable vehicle and are present in the finalcomposition, e.g., in an amount ranging from about 0.1% to about 20%,from about 0.5% to about 10%. In certain embodiments of the presentdisclosure, the amount of buffer included in the gel compositions is anamount such that the pH of the gel composition does not interfere withthe natural buffering system of the auris media or auris interna, ordoes not interfere with the natural pH of the endolymph or perilymph:depending on where in the cochlea the otic structure modulating agent orinnate immune system modulating agent composition is targeted. In someembodiments, from about 10 μM to about 200 mM concentration of a bufferis present in the gel composition. In certain embodiments, from about a5 mM to about a 200 mM concentration of a buffer is present. In certainembodiments, from about a 20 mM to about a 100 mM concentration of abuffer is present. In one embodiment is a buffer such as acetate orcitrate at slightly acidic pH. In one embodiment the buffer is a sodiumacetate buffer having a pH of about 4.5 to about 6.5. In one embodimentthe buffer is a sodium citrate buffer having a pH of about 5.0 to about8.0, or about 5.5 to about 7.0.

In an alternative embodiment, the buffer used istris(hydroxymethyl)aminomethane, bicarbonate, carbonate or phosphate atslightly basic pH. In one embodiment, the buffer is a sodium bicarbonatebuffer having a pH of about 6.5 to about 8.5, or about 7.0 to about 8.0.In another embodiment the buffer is a sodium phosphate dibasic bufferhaving a pH of about 6.0 to about 9.0.

Also described herein are controlled-release compositions or devicescomprising an otic structure modulating agent or innate immune systemmodulating agent and a viscosity enhancing agent. Suitableviscosity-enhancing agents include by way of example only, gellingagents and suspending agents. In one embodiment, the enhanced viscositycomposition does not include a buffer. In other embodiments, theenhanced viscosity composition includes a pharmaceutically acceptablebuffer. Sodium chloride or other tonicity agents are optionally used toadjust tonicity, if necessary.

By way of example only, the auris-acceptable viscosity agent includehydroxypropyl methylcellulose, hydroxyethyl cellulose,polyvinylpyrrolidone, carboxymethyl cellulose, polyvinyl alcohol, sodiumchondroitin sulfate, sodium hyaluronate. Other viscosity enhancingagents compatible with the targeted auris structure include, but are notlimited to, acacia (gum arabic), agar, aluminum magnesium silicate,sodium alginate, sodium stearate, bladderwrack, bentonite, carbomer,carrageenan, Carbopol, xanthan, cellulose, microcrystalline cellulose(MCC), ceratonia, chitin, carboxymethylated chitosan, chondrus,dextrose, furcellaran, gelatin, Ghatti gum, guar gum, hectorite,lactose, sucrose, maltodextrin, mannitol, sorbitol, honey, maize starch,wheat starch, rice starch, potato starch, gelatin, sterculia gum,xanthum gum, gum tragacanth, ethyl cellulose, ethylhydroxyethylcellulose, ethylmethyl cellulose, methyl cellulose, hydroxyethylcellulose, hydroxyethylmethyl cellulose, hydroxypropyl cellulose,poly(hydroxyethyl methacrylate), oxypolygelatin, pectin, polygeline,povidone, propylene carbonate, methyl vinyl ether/maleic anhydridecopolymer (PVM/MA), poly(methoxyethyl methacrylate),poly(methoxyethoxyethyl methacrylate), hydroxypropyl cellulose,hydroxypropylmethyl-cellulose (HPMC), sodium carboxymethyl-cellulose(CMC), silicon dioxide, polyvinylpyrrolidone (PVP: povidone), Splenda®(dextrose, maltodextrin and sucralose) or combinations thereof. Inspecific embodiments, the viscosity-enhancing excipient is a combinationof MCC and CMC. In another embodiment, the viscosity-enhancing agent isa combination of carboxymethylated chitosan, or chitin, and alginate.The combination of chitin and alginate with the otic structuremodulating agent or innate immune system modulating agents disclosedherein acts as a controlled-release composition, restricting thediffusion of the otic structure modulating agent or innate immune systemmodulating agents from the composition. Moreover, the combination ofcarboxymethylated chitosan and alginate is optionally used to assist inincreasing the permeability of the otic structure modulating agent orinnate immune system modulating agents through the round windowmembrane.

In some embodiments, is an enhanced viscosity composition, comprisingfrom about 0.1 mM and about 100 mM of an otic structure modulating agentor innate immune system modulating agent, a pharmaceutically acceptableviscosity agent, and water for injection, the concentration of theviscosity agent in the water being sufficient to provide a enhancedviscosity composition with a final viscosity from about 100 to about100,000 cP. In certain embodiments, the viscosity of the gel is in therange from about 100 to about 50,000 cP, about 100 cP to about 1,000 cP,about 500 cP to about 1500 cP, about 1000 cP to about 3000 cP, about2000 cP to about 8,000 cP, about 4,000 cP to about 50,000 cP, about10,000 cP to about 500,000 cP, about 15,000 cP to about 1,000,000 cP. Inother embodiments, when an even more viscous medium is desired, thebiocompatible gel comprises at least about 35%, at least about 45%, atleast about 55%, at least about 65%, at least about 70%, at least about75%, or even at least about 80% or so by weight of the otic structuremodulating agent or innate immune system modulating agent. In highlyconcentrated samples, the biocompatible enhanced viscosity compositioncomprises at least about 25%, at least about 35%, at least about 45%, atleast about 55%, at least about 65%, at least about 75%, at least about85%, at least about 90% or at least about 95% or more by weight of theotic structure modulating agent or innate immune system modulatingagent.

In some embodiments, the viscosity of the gel compositions presentedherein are measured by any means described. For example, in someembodiments, an LVDV-II+CP Cone Plate Viscometer and a Cone SpindleCPE-40 is used to calculate the viscosity of the gel compositiondescribed herein. In other embodiments, a Brookfield (spindle and cup)viscometer is used to calculate the viscosity of the gel compositiondescribed herein. In some embodiments, the viscosity ranges referred toherein are measured at room temperature. In other embodiments, theviscosity ranges referred to herein are measured at body temperature(e.g., at the average body temperature of a healthy human).

In one embodiment, the pharmaceutically acceptable enhanced viscosityauris-acceptable composition comprises an otic structure modulatingagent or innate immune system modulating agent and at least one gellingagent. Suitable gelling agents for use in preparation of the gelcomposition include, but are not limited to, celluloses, cellulosederivatives, cellulose ethers (e.g., carboxymethylcellulose,ethylcellulose, hydroxyethylcellulose, hydroxymethylcellulose,hydroxypropylmethylcellulose, hydroxypropylcellulose, methylcellulose),guar gum, xanthan gum, locust bean gum, alginates (e.g., alginic acid),silicates, starch, tragacanth, carboxyvinyl polymers, carrageenan,paraffin, petrolatum and any combinations or mixtures thereof. In someother embodiments, hydroxypropylmethylcellulose (Methocel®) is utilizedas the gelling agent. In certain embodiments, the viscosity enhancingagents described herein are also utilized as the gelling agent for thegel compositions presented herein.

In some embodiments, the otic therapeutic agents disclosed herein aredispensed as an auris-acceptable paint. As used herein, paints (alsoknown as film formers) are solutions comprised of a solvent, a monomeror polymer, an active agent, and optionally one or morepharmaceutically-acceptable excipients. After application to a tissue,the solvent evaporates leaving behind a thin coating comprised of themonomers or polymers, and the active agent. The coating protects activeagents and maintains them in an immobilized state at the site ofapplication. This decreases the amount of active agent that may be lostand correspondingly increases the amount delivered to the subject. Byway of non-limiting example, paints include collodions (e.g. FlexibleCollodion, USP), and solutions comprising saccharide siloxane copolymersand a cross-linking agent. Collodions are ethyl ether/ethanol solutionscontaining pyroxylin (a nitrocellulose). After application, the ethylether/ethanol solution evaporates leaving behind a thin film ofpyroxylin. In solutions comprising saccharide siloxane copolymers, thesaccharide siloxane copolymers form the coating after evaporation of thesolvent initiates the cross-linking of the saccharide siloxanecopolymers. For additional disclosures regarding paints, see Remington:The Science and Practice of Pharmacy that is hereby incorporated withrespect to this subject matter. The paints contemplated for use herein,are flexible such that they do not interfere with the propagation ofpressure waves through the ear. Further, the paints may be applied as aliquid (i.e. solution, suspension, or emulsion), a semisolid (i.e., agel, foam, paste, or jelly) or an aerosol.

In some embodiments, the otic therapeutic agents disclosed herein aredispensed as a controlled-release foam. Examples of suitable foamablecarriers for use in the compositions disclosed herein include, but arenot limited to, alginate and derivatives thereof, carboxymethylcelluloseand derivatives thereof, collagen, polysaccharides, including, forexample, dextran, dextran derivatives, pectin, starch, modified starchessuch as starches having additional carboxyl and/or carboxamide groupsand/or having hydrophilic side-chains, cellulose and derivativesthereof, agar and derivatives thereof, such as agar stabilized withpolyacrylamide, polyethylene oxides, glycol methacrylates, gelatin, gumssuch as xanthum, guar, karaya, gellan, arabic, tragacanth and locustbean gum, or combinations thereof. Also suitable are the salts of theaforementioned carriers, for example, sodium alginate. The compositionoptionally further comprises a foaming agent, which promotes theformation of the foam, including a surfactant or external propellant.Examples of suitable foaming agents include cetrimide, lecithin, soaps,silicones and the like. Commercially available surfactants such asTween® are also suitable.

In some embodiments, other gel compositions are useful depending uponthe particular otic structure modulating agent or innate immune systemmodulating agent, other pharmaceutical agent or excipients/additivesused, and as such are considered to fall within the scope of the presentdisclosure. For example, other commercially-available glycerin-basedgels, glycerin-derived compounds, conjugated, or crosslinked gels,matrices, hydrogels, and polymers, as well as gelatins and theirderivatives, alginates, and alginate-based gels, and even various nativeand synthetic hydrogel and hydrogel-derived compounds are all expectedto be useful in the otic structure modulating compositions describedherein. In some embodiments, auris-acceptable gels include, but are notlimited to, alginate hydrogels SAF®-Gel (ConvaTec, Princeton, N.J.),Duoderm® Hydroactive Gel (ConvaTec), Nu-gel® (Johnson & Johnson Medical,Arlington, Tex.); Carrasyn® (V) Acemannan Hydrogel (CarringtonLaboratories, Inc., Irving, Tex.); glycerin gels Elta® Hydrogel(Swiss-American Products, Inc., Dallas, Tex.) and K-Y® Sterile (Johnson& Johnson). In further embodiments, biodegradable biocompatible gelsalso represent compounds present in auris-acceptable compositionsdisclosed and described herein.

In some compositions developed for administration to a mammal, and forcompositions formulated for human administration, the auris-acceptablegel comprises substantially all of the weight of the composition. Inother embodiments, the auris-acceptable gel comprises as much as about98% or about 99% of the composition by weight. This is desirous when asubstantially non-fluid, or substantially viscous composition is needed.In a further embodiment, when slightly less viscous, or slightly morefluid auris-acceptable pharmaceutical gel compositions are desired, thebiocompatible gel portion of the composition comprises at least about50% by weight, at least about 60% by weight, at least about 70% byweight, or even at least about 80% or 90% by weight of the compound. Allintermediate integers within these ranges are contemplated to fallwithin the scope of this disclosure, and in some alternativeembodiments, even more fluid (and consequently less viscous)auris-acceptable gel compositions are formulated, such as for example,those in that the gel or matrix component of the mixture comprises notmore than about 50% by weight, not more than about 40% by weight, notmore than about 30% by weight, or even those than comprise not more thanabout 15% or about 20% by weight of the composition.

Auris-Acceptable Suspending Agents

In one embodiment, an otic structure modulating agent or innate immunesystem modulating agent is included in a pharmaceutically acceptableenhanced viscosity composition wherein the composition further comprisesat least one suspending agent, wherein the suspending agent assists inimparting controlled-release characteristics to the composition. In someembodiments, suspending agents also serve to increase the viscosity ofthe auris-acceptable otic structure modulating compositions andcompositions.

Suspending agents include, by way of example only, compounds such aspolyvinylpyrrolidone, e.g., polyvinylpyrrolidone K12,polyvinylpyrrolidone K17, polyvinylpyrrolidone K25, orpolyvinylpyrrolidone K30, vinyl pyrrolidone/vinyl acetate copolymer(S630), sodium carboxymethylcellulose, methylcellulose,hydroxypropylmethylcellulose (hypromellose), hydroxymethylcelluloseacetate stearate, polysorbate-80, hydroxyethylcellulose, sodiumalginate, gums, such as, e.g., gum tragacanth and gum acacia, guar gum,xanthans, including xanthan gum, sugars, cellulosics, such as, e.g.,sodium carboxymethylcellulose, methylcellulose, sodiumcarboxymethylcellulose, hydroxypropylmethylcellulose,hydroxyethylcellulose, polysorbate-80, sodium alginate, polyethoxylatedsorbitan monolaurate, polyethoxylated sorbitan monolaurate, povidone andthe like. In some embodiments, useful aqueous suspensions also containone or more polymers as suspending agents. Useful polymers includewater-soluble polymers such as cellulosic polymers, e.g., hydroxypropylmethylcellulose, and water-insoluble polymers such as cross-linkedcarboxyl-containing polymers.

In one embodiment, the present disclosure provides auris-acceptable gelcompositions comprising a therapeutically effective amount of an oticstructure modulating agent or innate immune system modulating agent in ahydroxyethyl cellulose gel. Hydroxyethyl cellulose (HEC) is obtained asa dry powder that is reconstituted in water or an aqueous buffersolution to give the desired viscosity (generally about 200 cps to about30,000 cps, corresponding to about 0.2 to about 10% HEC). In oneembodiment the concentration of HEC is between about 1% and about 15%,about 1% and about 2%, or about 1.5% to about 2%.

In other embodiments, the auris-acceptable compositions, including gelcompositions and viscosity-enhanced compositions, further includeexcipients, other medicinal or pharmaceutical agents, carriers,adjuvants, such as preserving, stabilizing, wetting or emulsifyingagents, solution promoters, salts, solubilizers, an antifoaming agent,an antioxidant, a dispersing agent, a wetting agent, a surfactant, andcombinations thereof.

Auris-Acceptable Actinic Radiation Curable Gel

In other embodiments, the gel is an actinic radiation curable gel, suchthat following administration to or near the targeted auris structure,use of actinic radiation (or light, including UV light, visible light,or infrared light) the desired gel properties are formed. By way ofexample only, fiber optics are used to provide the actinic radiation soas to form the desired gel properties. In some embodiments, the fiberoptics and the gel administration device form a single unit. In otherembodiments, the fiber optics and the gel administration device areprovided separately.

Auris-Acceptable Solvent Release Gel

In some embodiments, the gel is a solvent release gel such that thedesired gel properties are formed after administration to or near thetargeted auris structure, which is, as the solvent in the injected gelcomposition diffuses out the gel, a gel having the desired gelproperties is formed. For example, a composition that comprises sucroseacetate isobutyrate, a pharmaceutically acceptable solvent, one or moreadditives, and the otic structure modulating agent or innate immunesystem modulating agent is administered at or near the round windowmembrane: diffusion of the solvent out of the injected compositionprovides a depot having the desired gel properties. For example, use ofa water soluble solvent provides a high viscosity depot when the solventdiffuses rapidly out of the injected composition. On the other hand, useof a hydrophobic solvent (e.g., benzyl benzoate) provides a less viscousdepot. One example of an auris-acceptable solvent release gelcomposition is the SABER™ Delivery System marketed by DURECTCorporation.

Auris-Acceptable In Situ Forming Spongy Material

Also contemplated within the scope of the embodiments is the use of aspongy material, formed in situ in the auris interna or auris media. Insome embodiments, the spongy material is formed from hyaluronic acid orits derivatives. The spongy material is impregnated with a desired oticstructure modulating agent or innate immune system modulating agent andplaced within the auris media so as to provide controlled-release of theotic structure modulating agent or innate immune system modulating agentwithin the auris media, or in contact with the round window membrane soas to provide controlled-release of the otic structure modulating agentor innate immune system modulating agent into the auris interna. In someembodiments, the spongy material is biodegradable.

Round Window Membrane Mucoadhesives

Also contemplated within the scope of the embodiments is the addition ofa round window membrane mucoadhesive with the otic structure modulatingcompositions and devices disclosed herein. The term ‘mucoadhesion’ isused for materials that bind to the mucin layer of a biologicalmembrane, such as the external membrane of the 3-layered round windowmembrane. To serve as round window membrane mucoadhesive polymers, thepolymers possess some general physiochemical features such aspredominantly anionic hydrophilicity with numerous hydrogen bond forminggroups, suitable surface property for wetting mucus/mucosal tissuesurfaces or sufficient flexibility to penetrate the mucus network.

Round window membrane mucoadhesive agents that are used with theauris-acceptable compositions include, but are not limited to, at leastone soluble polyvinylpyrrolidone polymer (PVP); a water-swellable, butwater-insoluble, fibrous, cross-linked carboxy-functional polymer; acrosslinked poly(acrylic acid) (e.g. Carbopol® 947P); a carbomerhomopolymer; a carbomer copolymer; a hydrophilic polysaccharide gum,maltodextrin, a cross-linked alignate gum gel, a water-dispersiblepolycarboxylated vinyl polymer, at least two particulate componentsselected from the group consisting of titanium dioxide, silicon dioxide,and clay, or a mixture thereof. The round window membrane mucoadhesiveagent is optionally used in combination with an auris-acceptableviscosity increasing excipient, or used alone to increase theinteraction of the composition with the mucosal layer target oticcomponent. In one non-limiting example, the mucoadhesive agent ismaltodextrin and/or an alginate gum. When used, the round windowmembrane mucoadhesive character imparted to the composition is at alevel that is sufficient to deliver an effective amount of the oticstructure modulating agent or innate immune system modulating agentcomposition to, for example, the mucosal layer of round window membraneor the crista fenestrae cochleae in an amount that coats the mucosalmembrane, and thereafter deliver the composition to the affected areas,including by way of example only, the vestibular and/or cochlearstructures of the auris interna. When used, the mucoadhesivecharacteristics of the compositions provided herein are determined, andusing this information (along with the other teachings provided herein),the appropriate amounts are determined. One method for determiningsufficient mucoadhesiveness includes monitoring changes in theinteraction of the composition with a mucosal layer, including but notlimited to measuring changes in residence or retention time of thecomposition in the absence and presence of the mucoadhesive excipient.

Mucoadhesive agents have been described, for example, in U.S. Pat. Nos.6,638,521, 6,562,363, 6,509,028, 6,348,502, 6,319,513, 6,306,789,5,814,330, and 4,900,552, each of that is hereby incorporated byreference for such disclosure.

In another non-limiting example, a mucoadhesive agent is, for example,at least two particulate components selected from titanium dioxide,silicon dioxide, and clay, wherein the composition is not furtherdiluted with any liquid prior to administration and the level of silicondioxide, if present, is from about 3% to about 15%, by weight of thecomposition. Silicon dioxide, if present, includes fumed silicondioxide, precipitated silicon dioxide, coacervated silicon dioxide, gelsilicon dioxide, and mixtures thereof. Clay, if present, includes kaolinminerals, serpentine minerals, smectites, illite or a mixture thereof.For example, clay includes laponite, bentonite, hectorite, saponite,montmorillonites or a mixture thereof.

In one non-limiting example, the round window membrane mucoadhesiveagent is maltodextrin. Maltodextrin is a carbohydrate produced by thehydrolysis of starch that is optionally derived from corn, potato, wheator other plant products. Maltodextrin is optionally used either alone orin combination with other round window membrane mucoadhesive agents toimpart mucoadhesive characteristics on the compositions disclosedherein. In one embodiment, a combination of maltodextrin and a carbopolpolymer are used to increase the round window membrane mucoadhesivecharacteristics of the compositions or devices disclosed herein.

In another embodiment, the round window membrane mucoadhesive agent isan alkyl-glycoside and/or a saccharide alkyl ester. As used herein, an“alkyl-glycoside” means a compound comprising any hydrophilic saccharide(e.g. sucrose, maltose, or glucose) linked to a hydrophobic alkyl. Insome embodiments, the round window membrane mucoadhesive agent is analkyl-glycoside wherein the alkyl-glycoside comprises a sugar linked toa hydrophobic alkyl (e.g., an alkyl comprising about 6 to about 25carbon atoms) by an amide linkage, an amine linkage, a carbamatelinkage, an ether linkage, a thioether linkage, an ester linkage, athioester linkage, a glycosidic linkage, a thioglycosidic linkage,and/or a ureide linkage. In some embodiments, the round window membranemucoadhesive agent is a hexyl-, heptyl-, octyl-, nonyl-, decyl-,undecyl-, dodecyl-, tridecyl-, tetradecyl, pentadecyl-, hexadecyl-,heptadecyl-, and octadecyl α- or β-D-maltoside; hexyl-, heptyl-, octyl-,nonyl-, decyl-, undecyl-, dodecyl-, tridecyl-, tetradecyl, pentadecyl-,hexadecyl-, heptadecyl-, and octadecyl α- or β-D-glucoside; hexyl-,heptyl-, octyl-, nonyl-, decyl-, undecyl-, dodecyl-, tridecyl-,tetradecyl, pentadecyl-, hexadecyl-, heptadecyl-, and octadecyl α- orβ-D-sucroside; hexyl-, heptyl-, octyl-, dodecyl-, tridecyl-, andtetradecyl-β-D-thiomaltoside; heptyl- or octyl-1-thio-α- orβ-D-glucopyranoside; alkyl thiosucroses; alkyl maltotriosides; longchain aliphatic carbonic acid amides of sucrose β-amino-alkyl ethers;derivatives of palatinose or isomaltamine linked by an amide linkage toan alkyl chain and derivatives of isomaltamine linked by urea to analkyl chain; long chain aliphatic carbonic acid ureides of sucroseβ-amino-alkyl ethers and long chain aliphatic carbonic acid amides ofsucrose β-amino-alkyl ethers. In some embodiments, the round windowmembrane mucoadhesive agent is an alkyl-glycoside wherein the alkylglycoside is maltose, sucrose, glucose, or a combination thereof linkedby a glycosidic linkage to an alkyl chain of 9-16 carbon atoms (e.g.,nonyl-, decyl-, dodecyl- and tetradecyl sucroside; nonyl-, decyl-,dodecyl- and tetradecyl glucoside; and nonyl-, decyl-, dodecyl- andtetradecyl maltoside). In some embodiments, the round window membranemucoadhesive agent is an alkyl-glycoside wherein the alkyl glycoside isdodecylmaltoside, tridecylmaltoside, and tetradecylmaltoside.

In some embodiments, the round window membrane mucoadhesive agent is analkyl-glycoside wherein the alkyl-glycoside is a disaccharide with atleast one glucose. In some embodiments, the auris acceptable penetrationenhancer is a surfactant comprisingα-D-glucopyranosyl-β-glycopyranoside,n-Dodecyl-4-O-α-D-glucopyranosyl-β-glycopyranoside, and/orn-tetradecyl-4-O-α-D-glucopyranosyl-β-glycopyranoside. In someembodiments, the round window membrane mucoadhesive agent is analkyl-glycoside wherein the alkyl-glycoside has a critical miscelleconcentration (CMC) of less than about 1 mM in pure water or in aqueoussolutions. In some embodiments, the round window membrane mucoadhesiveagent is an alkyl-glycoside wherein an oxygen atom within thealkyl-glycoside is substituted with a sulfur atom. In some embodiments,the round window membrane mucoadhesive agent is an alkyl-glycosidewherein the alkylglycoside is the β anomer. In some embodiments, theround window membrane mucoadhesive agent is an alkyl-glycoside whereinthe alkylglycoside comprises 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%,98%, 99%, 99.1%, 99.5%, or 99.9% of the β anomer.

Auris-Acceptable Controlled-Release Particles

Otic structure modulating agent or innate immune system modulatingagents and/or other pharmaceutical agents disclosed herein areoptionally incorporated within controlled-release particles, lipidcomplexes, liposomes, nanoparticles, microparticles, microspheres,coacervates, nanocapsules or other agents that enhance or facilitate thelocalized delivery of the otic structure modulating agent or innateimmune system modulating agent. In some embodiments, a single enhancedviscosity composition is used, in that an otic structure modulatingagent or innate immune system modulating agent is present, while inother embodiments, a pharmaceutical composition that comprises a mixtureof two or more distinct enhanced viscosity compositions is used, in thatan otic structure modulating agent or innate immune system modulatingagent is present. In some embodiments, combinations of sols, gels and/orbiocompatible matrices is also employed to provide desirablecharacteristics of the controlled-release otic structure modulatingcompositions or compositions. In certain embodiments, thecontrolled-release otic structure modulating compositions orcompositions are cross-linked by one or more agents to alter or improvethe properties of the composition.

Examples of microspheres relevant to the pharmaceutical compositionsdisclosed herein include: Luzzi, L. A., J. Pharm. Psy. 59:1367 (1970);U.S. Pat. No. 4,530,840; Lewis, D. H., “Controlled-release of BioactiveAgents from Lactides/Glycolide Polymers” in Biodegradable Polymers asDrug Delivery Systems, Chasin, M. and Langer, R., eds., Marcel Decker(1990); U.S. Pat. No. 4,675,189; Beck et al., “Poly(lactic acid) andPoly(lactic acid-co-glycolic acid) Contraceptive Delivery Systems,” inLong Acting Steroid Contraception, Mishell, D. R., ed., Raven Press(1983); U.S. Pat. No. 4,758,435; U.S. Pat. No. 3,773,919; U.S. Pat. No.4,474,572. Examples of protein therapeutics formulated as microspheresinclude: U.S. Pat. No. 6,458,387; U.S. Pat. No. 6,268,053; U.S. Pat. No.6,090,925; U.S. Pat. No. 5,981,719; and U.S. Pat. No. 5,578,709, and areherein incorporated by reference for such disclosure.

Microspheres usually have a spherical shape, although irregularly-shapedmicroparticles are possible. Microspheres may vary in size, ranging fromsubmicron to 1000 micron diameters. Microspheres suitable for use withthe auris-acceptable compositions disclosed herein are submicron to 250micron diameter microspheres, allowing administration by injection witha standard gauge needle. The auris-acceptable microspheres are preparedby any method that produces microspheres in a size range acceptable foruse in an injectable composition. Injection is optionally accomplishedwith standard gauge needles used for administering liquid compositions.

Suitable examples of polymeric matrix materials for use in theauris-acceptable controlled-release particles herein includepoly(glycolic acid), poly-d,1-lactic acid, poly-1-lactic acid,copolymers of the foregoing, poly(aliphatic carboxylic acids),copolyoxalates, polycaprolactone, polydioxonene, poly(orthocarbonates),poly(acetals), poly(lactic acid-caprolactone), polyorthoesters,poly(glycolic acid-caprolactone), polydioxonene, polyanhydrides,polyphosphazines, and natural polymers including albumin, casein, andsome waxes, such as, glycerol mono- and distearate, and the like.Various commercially available poly (lactide-co-glycolide) materials(PLGA) are optionally used in the method disclosed herein. For example,poly (d,1-lactic-co-glycolic acid) is commercially available fromBoehringer-Ingelheim as RESOMER RG 503H. This product has a mole percentcomposition of 50% lactide and 50% glycolide. These copolymers areavailable in a wide range of molecular weights and ratios of lactic acidto glycolic acid. One embodiment includes the use of the polymerpoly(d,1-lactide-co-glycolide). The molar ratio of lactide to glycolidein such a copolymer includes the range of from about 95:5 to about50:50.

The molecular weight of the polymeric matrix material is of someimportance. The molecular weight should be high enough so that it formssatisfactory polymer coatings, i.e., the polymer should be a good filmformer. Usually, a satisfactory molecular weight is in the range of5,000 to 500,000 Daltons. The molecular weight of a polymer is alsoimportant from the point of view that molecular weight influences thebiodegradation rate of the polymer. For a diffusional mechanism of drugrelease, the polymer should remain intact until all of the drug isreleased from the microparticles and then degrade. The drug is alsoreleased from the microparticles as the polymeric excipient bioerodes.By an appropriate selection of polymeric materials a microspherecomposition is made such that the resulting microspheres exhibit bothdiffusional release and biodegradation release properties. This isuseful in affording multiphasic release patterns.

A variety of methods are known by that compounds are encapsulated inmicrospheres. In these methods, the otic structure modulating agent orinnate immune system modulating agent is generally dispersed oremulsified, using stirrers, agitators, or other dynamic mixingtechniques, in a solvent containing a wall-forming material. Solvent isthen removed from the microspheres, and thereafter the microsphereproduct is obtained.

In one embodiment, controlled-release otic structure modulatingcompositions are made through the incorporation of the otic structuremodulating agent or innate immune system modulating agents and/or otherpharmaceutical agents into ethylene-vinyl acetate copolymer matrices.(See U.S. Pat. No. 6,083,534, incorporated herein for such disclosure).In another embodiment, otic structure modulating agent or innate immunesystem modulating agents are incorporated into poly (lactic-glycolicacid) or poly-L-lactic acid microspheres. Id. In yet another embodiment,the otic structure modulating agent or innate immune system modulatingagents are encapsulated into alginate microspheres. (See U.S. Pat. No.6,036,978, incorporated herein for such disclosure). Biocompatiblemethacrylate-based polymers to encapsulate the otic structure modulatingcompounds or compositions are optionally used in the compositions andmethods disclosed herein. A wide range of methacrylate-based polymersystems are commercially available, such as the EUDRAGIT polymersmarketed by Evonik. One useful aspect of methacrylate polymers is thatthe properties of the composition are varied by incorporating variousco-polymers. For example, poly(acrylic acid-co-methylmethacrylate)microparticles exhibit enhanced mucoadhesion properties as thecarboxylic acid groups in the poly(acrylic acid) form hydrogen bondswith mucin (Park et al, Pharm. Res. (1987) 4(6):457-464). Variation ofthe ratio between acrylic acid and methylmethacrylate monomers serves tomodulate the properties of the co-polymer. Methacrylate-basedmicroparticles have also been used in protein therapeutic compositions(Naha et al, Journal of Microencapsulation 4 Feb., 2008 (onlinepublication)). In one embodiment, the enhanced viscosityauris-acceptable compositions described herein comprises otic structuremodulating microspheres wherein the microspheres are formed from amethacrylate polymer or copolymer. In an additional embodiment, theenhanced viscosity composition described herein comprises otic structuremodulating microspheres wherein the microspheres are mucoadhesive. Othercontrolled-release systems, including incorporation or deposit ofpolymeric materials or matrices onto solid or hollow spheres containingotic structure modulating agent or innate immune system modulatingagents, are also explicitly contemplated within the embodimentsdisclosed herein. The types of controlled-release systems availablewithout significantly losing activity of the otic structure modulatingagent or innate immune system modulating agent are determined using theteachings, examples, and principles disclosed herein

An example of a conventional microencapsulation process forpharmaceutical preparations is shown in U.S. Pat. No. 3,737,337,incorporated herein by reference for such disclosure. The otic structuremodulating substances to be encapsulated or embedded are dissolved ordispersed in the organic solution of the polymer (phase A), usingconventional mixers, including (in the preparation of dispersion)vibrators and high-speed stirrers, etc. The dispersion of phase (A),containing the core material in solution or in suspension, is carriedout in the aqueous phase (B), again using conventional mixers, such ashigh-speed mixers, vibration mixers, or even spray nozzles, in that casethe particle size of the microspheres will be determined not only by theconcentration of phase (A), but also by the emulsate or microspheresize. With conventional techniques for the microencapsulation of an oticstructure modulating agent or innate immune system modulating agents,the microspheres form when the solvent containing an active agent and apolymer is emulsified or dispersed in an immiscible solution bystirring, agitating, vibrating, or some other dynamic mixing technique,often for a relatively long period of time.

Methods for the construction of microspheres are also described in U.S.Pat. No. 4,389,330, and U.S. Pat. No. 4,530,840, incorporated herein byreference for such disclosure. The desired otic structure modulatingagent or innate immune system modulating agent is dissolved or dispersedin an appropriate solvent. To the agent-containing medium is added thepolymeric matrix material in an amount relative to the active ingredientthat gives a product of the desired loading of active agent. Optionally,all of the ingredients of the otic structure modulating microsphereproduct can be blended in the solvent medium together. Suitable solventsfor the agent and the polymeric matrix material include organic solventssuch as acetone, halogenated hydrocarbons such as chloroform, methylenechloride and the like, aromatic hydrocarbon compounds, halogenatedaromatic hydrocarbon compounds, cyclic ethers, alcohols, ethyl acetateand the like.

The mixture of ingredients in the solvent is emulsified in acontinuous-phase processing medium; the continuous-phase medium beingsuch that a dispersion of microdroplets containing the indicatedingredients is formed in the continuous-phase medium. Naturally, thecontinuous-phase processing medium and the organic solvent must beimmiscible, and includes water although nonaqueous media such as xyleneand toluene and synthetic oils and natural oils are optionally used.Optionally, a surfactant is added to the continuous-phase processingmedium to prevent the microparticles from agglomerating and to controlthe size of the solvent microdroplets in the emulsion. A preferredsurfactant-dispersing medium combination is a 1 to 10 wt. % poly (vinylalcohol) in water mixture. The dispersion is formed by mechanicalagitation of the mixed materials. An emulsion is optionally formed byadding small drops of the active agent-wall forming material solution tothe continuous phase processing medium. The temperature during theformation of the emulsion is not especially critical but influences thesize and quality of the microspheres and the solubility of the drug inthe continuous phase. It is desirable to have as little of the agent inthe continuous phase as possible. Moreover, depending on the solvent andcontinuous-phase processing medium employed, the temperature must not betoo low or the solvent and processing medium will solidify or theprocessing medium will become too viscous for practical purposes, or toohigh that the processing medium will evaporate, or that the liquidprocessing medium will not be maintained. Moreover, the temperature ofthe medium cannot be so high that the stability of the particular agentbeing incorporated in the microspheres is adversely affected.Accordingly, the dispersion process is conducted at any temperature thatmaintains stable operating conditions, which preferred temperature beingabout 15° C. to 60° C., depending upon the drug and excipient selected.

The dispersion that is formed is a stable emulsion and from thisdispersion the organic solvent immiscible fluid is optionally partiallyremoved in the first step of the solvent removal process. The solvent isremoved by techniques such as heating, the application of a reducedpressure or a combination of both. The temperature employed to evaporatesolvent from the microdroplets is not critical, but should not be thathigh that it degrades the otic structure modulating agent or innateimmune system modulating agent employed in the preparation of a givenmicroparticle, nor should it be so high as to evaporate solvent at sucha rapid rate to cause defects in the wall forming material. Generally,from 5 to 75%, of the solvent is removed in the first solvent removalstep.

After the first stage, the dispersed microparticles in the solventimmiscible fluid medium are isolated from the fluid medium by anyconvenient means of separation. Thus, for example, the fluid is decantedfrom the microsphere or the microsphere suspension is filtered. Stillother, various combinations of separation techniques are used ifdesired.

Following the isolation of the microspheres from the continuous-phaseprocessing medium, the remainder of the solvent in the microspheres isremoved by extraction. In this step, the microspheres are suspended inthe same continuous-phase processing medium used in step one, with orwithout surfactant, or in another liquid. The extraction medium removesthe solvent from the microspheres and yet does not dissolve themicrospheres. During the extraction, the extraction medium withdissolved solvent is optionally removed and replaced with freshextraction medium. This is best done on a continual basis. The rate ofextraction medium replenishment of a given process is a variable that isdetermined at the time the process is performed and, therefore, noprecise limits for the rate must be predetermined. After the majority ofthe solvent has been removed from the microspheres, the microspheres aredried by exposure to air or by other conventional drying techniques suchas vacuum drying, drying over a desiccant, or the like. This process isvery efficient in encapsulating the otic structure modulating agent orinnate immune system modulating agent since core loadings of up to 80wt. %, preferably up to 60 wt. % are obtained.

Alternatively, controlled-release microspheres containing an oticstructure modulating agent or innate immune system modulating agent isprepared through the use of static mixers. Static or motionless mixersconsist of a conduit or tube in that is received a number of staticmixing agents. Static mixers provide homogeneous mixing in a relativelyshort length of conduit, and in a relatively short period of time. Withstatic mixers, the fluid moves through the mixer, rather than some partof the mixer, such as a blade, moving through the fluid.

A static mixer is optionally used to create an emulsion. When using astatic mixer to form an emulsion, several factors determine emulsionparticle size, including the density and viscosity of the varioussolutions or phases to be mixed, volume ratio of the phases, interfacialtension between the phases, static mixer parameters (conduit diameter;length of mixing element; number of mixing elements), and linearvelocity through the static mixer. Temperature is a variable because itaffects density, viscosity, and interfacial tension. The controllingvariables are linear velocity, sheer rate, and pressure drop per unitlength of static mixer.

In order to create microspheres containing an otic structure modulatingagent or innate immune system modulating agent using a static mixerprocess, an organic phase and an aqueous phase are combined. The organicand aqueous phases are largely or substantially immiscible, with theaqueous phase constituting the continuous phase of the emulsion. Theorganic phase includes an otic structure modulating agent or innateimmune system modulating agent as well as a wall-forming polymer orpolymeric matrix material. The organic phase is prepared by dissolvingan otic structure modulating agent or innate immune system modulatingagent in an organic or other suitable solvent, or by forming adispersion or an emulsion containing the otic structure modulating agentor innate immune system modulating agent. The organic phase and theaqueous phase are pumped so that the two phases flow simultaneouslythrough a static mixer, thereby forming an emulsion that comprisesmicrospheres containing the otic structure modulating agent or innateimmune system modulating agent encapsulated in the polymeric matrixmaterial. The organic and aqueous phases are pumped through the staticmixer into a large volume of quench liquid to extract or remove theorganic solvent. Organic solvent is optionally removed from themicrospheres while they are washing or being stirred in the quenchliquid. After the microspheres are washed in a quench liquid, they areisolated, as through a sieve, and dried.

In one embodiment, microspheres are prepared using a static mixer. Theprocess is not limited to the solvent extraction technique discussedabove, but is used with other encapsulation techniques. For example, theprocess is optionally used with a phase separation encapsulationtechnique. To do so, an organic phase is prepared that comprises an oticstructure modulating agent or innate immune system modulating agentsuspended or dispersed in a polymer solution. The non-solvent secondphase is free from solvents for the polymer and active agent. Apreferred non-solvent second phase is silicone oil. The organic phaseand the non-solvent phase are pumped through a static mixer into anon-solvent quench liquid, such as heptane. The semi-solid particles arequenched for complete hardening and washing. The process ofmicroencapsulation includes spray drying, solvent evaporation, acombination of evaporation and extraction, and melt extrusion.

In another embodiment, the microencapsulation process involves the useof a static mixer with a single solvent. This process is described indetail in U.S. application Ser. No. 08/338,805, herein incorporated byreference for such disclosure. An alternative process involves the useof a static mixer with co-solvents. In this process, biodegradablemicrospheres comprising a biodegradable polymeric binder and an oticstructure modulating agent or innate immune system modulating agent areprepared, which comprises a blend of at least two substantiallynon-toxic solvents, free of halogenated hydrocarbons to dissolve boththe agent and the polymer. The solvent blend containing the dissolvedagent and polymer is dispersed in an aqueous solution to form droplets.The resulting emulsion is then added to an aqueous extraction mediumpreferably containing at least one of the solvents of the blend, wherebythe rate of extraction of each solvent is controlled, whereupon thebiodegradable microspheres containing the pharmaceutically active agentare formed. This process has the advantage that less extraction mediumis required because the solubility of one solvent in water issubstantially independent of the other and solvent selection isincreased, especially with solvents that are particularly difficult toextract.

Nanoparticles are also contemplated for use with the otic structuremodulating agent or innate immune system modulating agents disclosedherein. Nanoparticles are material structures of about 100 nm or less insize. One use of nanoparticles in pharmaceutical compositions is theformation of suspensions as the interaction of the particle surface withsolvent is strong enough to overcome differences in density.Nanoparticle suspensions are sterilized as the nanoparticles are smallenough to be subjected to sterilizing filtration (see, e.g., U.S. Pat.No. 6,139,870, herein incorporated by reference for such disclosure).Nanoparticles comprise at least one hydrophobic, water-insoluble andwater-indispersible polymer or copolymer emulsified in a solution oraqueous dispersion of surfactants, phospholipids or fatty acids. Theotic structure modulating agent or innate immune system modulating agentis optionally introduced with the polymer or the copolymer into thenanoparticles.

Lipid nanocapsules as controlled-release structures, as well forpenetrating the round window membrane and reaching auris interna and/orauris media targets, is also contemplated herein. Lipid nanocapsules areoptionally formed by emulsifying capric and caprylic acid triglycerides(Labrafac WL 1349; avg. mw 512), soybean lecithin (LIPOID® S75-3; 69%phosphatidylcholine and other phospholipids), surfactant (for example,Solutol HS15), a mixture of polyethylene glycol 660 hydroxystearate andfree polyethylene glycol 660; NaCl and water. The mixture is stirred atroom temperature to obtain an oil emulsion in water. After progressiveheating at a rate of 4° C./min under magnetic stirring, a short intervalof transparency should occur close to 70° C., and the inverted phase(water droplets in oil) obtained at 85° C. Three cycles of cooling andheating is then applied between 85° C. and 60° C. at the rate of 4°C./min, and a fast dilution in cold water at a temperature close to 0°C. to produce a suspension of nanocapsules. To encapsulate the oticstructure modulating agent or innate immune system modulating agents,the agent is optionally added just prior to the dilution with coldwater.

Otic structure modulating agent or innate immune system modulatingagents are also inserted into the lipid nanocapsules by incubation for90 minutes with an aqueous micellar solution of the auris active agent.The suspension is then vortexed every 15 minutes, and then quenched inan ice bath for 1 minute.

Suitable auris-acceptable surfactants are, by way of example, cholicacid or taurocholic acid salts. Taurocholic acid, the conjugate formedfrom cholic acid and taurine, is a fully metabolizable sulfonic acidsurfactant. An analog of taurocholic acid, tauroursodeoxycholic acid(TUDCA), is a naturally occurring bile acid and is a conjugate oftaurine and ursodeoxycholic acid (UDCA). Other naturally occurringanionic (e.g., galactocerebroside sulfate), neutral (e.g.,lactosylceramide) or zwitterionic surfactants (e.g., sphingomyelin,phosphatidyl choline, palmitoyl carnitine) are optionally used toprepare nanoparticles.

The auris-acceptable phospholipids are chosen, by way of example, fromnatural, synthetic or semi-synthetic phospholipids; lecithins(phosphatidylcholine) such as, for example, purified egg or soyalecithins (lecithin E100, lecithin E80 and phospholipons, for examplephospholipon 90), phosphatidylethanolamine, phosphatidylserine,phosphatidylinositol, phosphatidylglycerol,dipalmitoylphosphatidylcholine, dipalmitoylglycerophosphatidylcholine,dimyristoylphosphatidylcholine, distearoylphosphatidylcholine andphosphatidic acid or mixtures thereof are used more particularly.

Fatty acids for use with the auris-acceptable compositions are chosenfrom, by way of example, lauric acid, mysristic acid, palmitic acid,stearic acid, isostearic acid, arachidic acid, behenic acid, oleic acid,myristoleic acid, palmitoleic acid, linoleic acid, alpha-linoleic acid,arachidonic acid, eicosapentaenoic acid, erucic acid, docosahexaenoicacid, and the like.

Suitable auris-acceptable surfactants are selected from known organicand inorganic pharmaceutical excipients. Such excipients include variouspolymers, low molecular weight oligomers, natural products, andsurfactants. Preferred surface modifiers include nonionic and ionicsurfactants. Two or more surface modifiers are used in combination.

Representative examples of auris-acceptable surfactants include cetylpyridinium chloride, gelatin, casein, lecithin (phosphatides), dextran,glycerol, gum acacia, cholesterol, tragacanth, stearic acid, calciumstearate, glycerol monostearate, cetostearyl alcohol, cetomacrogolemulsifying wax, sorbitan esters, polyoxyethylene alkyl ethers,polyoxyethylene castor oil derivatives, polyoxyethylene sorbitan fattyacid esters; dodecyl trimethyl ammonium bromide,polyoxyethylenestearates, colloidal silicon dioxide, phosphates, sodiumdodecylsulfate, carboxymethylcellulose calcium, hydroxypropyl cellulose(HPC, HPC-SL, and HPC-L), hydroxypropyl methylcellulose (HPMC),carboxymethylcellulose sodium, methylcellulose, hydroxyethylcellulose,hydroxypropylcellulose, hydroxypropylmethyl-cellulose phthalate,noncrystalline cellulose, magnesium aluminum silicate, triethanolamine,polyvinyl alcohol (PVA), polyvinylpyrrolidone (PVP),4-(1,1,3,3-tetaamethylbutyl)-phenol polymer with ethylene oxide andformaldehyde (also known as tyloxapol, superione, and triton),poloxamers, poloxamines, a charged phospholipid such as dimyristoylphophatidyl glycerol, dioctylsulfosuccinate (DOSS); Tetronic® 1508,dialkylesters of sodium sulfosuccinic acid, Duponol P, Tritons X-200,Crodestas F-110, p-isononylphenoxypoly-(glycidol), Crodestas SL-40(Croda, Inc.); and SA9OHCO, which is C₁₈H₃₇CH₂ (CON(CH₃)—CH₂ (CHOH)₄(CH₂ OH)₂ (Eastman Kodak Co.); decanoyl-N-methylglucamide; n-decylβ-D-glucopyranoside; n-decyl β-D-maltopyranoside; n-dodecylβ-D-glucopyranoside; n-dodecyl β-D-maltoside;heptanoyl-N-methylglucamide; n-heptyl-β-D-glucopyranoside; n-heptylβ-D-thioglucoside; n-hexyl β-D-glucopyranoside;nonanoyl-N-methylglucamide; n-noyl β-D-glucopyranoside;octanoyl-N-methylglucamide; n-octyl-β-D-glucopyranoside; octylβ-D-thioglucopyranoside; and the like. Most of these surfactants areknown pharmaceutical excipients and are described in detail in theHandbook of Pharmaceutical Excipients, published jointly by the AmericanPharmaceutical Association and The Pharmaceutical Society of GreatBritain (The Pharmaceutical Press, 1986), specifically incorporated byreference for such disclosure.

The hydrophobic, water-insoluble and water-indispersible polymer orcopolymer may be chosen from biocompatible and biodegradable polymers,for example lactic or glycolic acid polymers and copolymers thereof, orpolylactic/polyethylene (or polypropylene) oxide copolymers, preferablywith molecular weights of between 1000 and 200,000, polyhydroxybutyricacid polymers, polylactones of fatty acids containing at least 12 carbonatoms, or polyanhydrides.

The nanoparticles may be obtained by coacervation, or the technique ofevaporation of solvent, from an aqueous dispersion or solution ofphospholipids and of an oleic acid salt into that is added an immiscibleorganic phase comprising the active principle and the hydrophobic,water-insoluble and water-indispersible polymer or copolymer. Themixture is pre-emulsified and then subjected to homogenization andevaporation of the organic solvent to obtain an aqueous suspension ofvery small-sized nanoparticles.

A variety of methods are optionally employed to fabricate the oticstructure modulating nanoparticles that are within the scope of theembodiments. These methods include vaporization methods, such as freejet expansion, laser vaporization, spark erosion, electro explosion andchemical vapor deposition; physical methods involving mechanicalattrition (e.g., “pearlmilling” technology, Elan Nanosystems), supercritical CO2 and interfacial deposition following solvent displacement.In one embodiment, the solvent displacement method is used. The size ofnanoparticles produced by this method is sensitive to the concentrationof polymer in the organic solvent; the rate of mixing; and to thesurfactant employed in the process. Continuous flow mixers provide thenecessary turbulence to ensure small particle size. One type ofcontinuous flow mixing device that is optionally used to preparenanoparticles has been described (Hansen et al J Phys Chem 92, 2189-96,1988). In other embodiments, ultrasonic devices, flow throughhomogenizers or supercritical CO2 devices may be used to preparenanoparticles.

If suitable nanoparticle homogeneity is not obtained on directsynthesis, then size-exclusion chromatography is used to produce highlyuniform drug-containing particles that are freed of other componentsinvolved in their fabrication. Size-exclusion chromatography (SEC)techniques, such as gel-filtration chromatography, is used to separateparticle-bound otic structure modulating agent or innate immune systemmodulating agent or other pharmaceutical compound from free oticstructure modulating agent or innate immune system modulating agent orother pharmaceutical compound, or to select a suitable size range ofotic structure modulating-containing nanoparticles. Various SEC media,such as Superdex 200, Superose 6, Sephacryl 1000 are commerciallyavailable and are employed for the size-based fractionation of suchmixtures. Additionally, nanoparticles are optionally purified bycentrifugation, membrane filtration and by use of other molecularsieving devices, crosslinked gels/materials and membranes.

Auris-Acceptable Cyclodextrin and Other Stabilizing Compositions

In a specific embodiment, the auris-acceptable formulationsalternatively comprise a cyclodextrin. Cyclodextrins are cyclicoligosaccharides containing 6, 7, or 8 glucopyranose units, referred toas α-cyclodextrin, β-cyclodextrin, or γ-cyclodextrin respectively.Cyclodextrins have a hydrophilic exterior, which enhanceswater-solublility, and a hydrophobic interior, which forms a cavity. Inan aqueous environment, hydrophobic portions of other molecules oftenenter the hydrophobic cavity of cyclodextrin to form inclusioncompounds. Additionally, cyclodextrins are capable of other types ofnonbonding interactions with molecules that are not inside thehydrophobic cavity. Cyclodextrins have three free hydroxyl groups foreach glucopyranose unit, or 18 hydroxyl groups on α-cyclodextrin, 21hydroxyl groups on β-cyclodextrin, and 24 hydroxyl groups onγ-cyclodextrin. One or more of these hydroxyl groups can be reacted withany of a number of reagents to form a large variety of cyclodextrinderivatives, including hydroxypropyl ethers, sulfonates, andsulfoalkylethers. Shown below is the structure of β-cyclodextrin and thehydroxypropyl-β-cyclodextrin (HPβCD).

In some embodiments, the use of cyclodextrins in the pharmaceuticalcompositions described herein improves the solubility of the drug.Inclusion compounds are involved in many cases of enhanced solubility;however other interactions between cyclodextrins and insoluble compoundsalso improves solubility. Hydroxypropyl-β-cyclodextrin (HPβCD) iscommercially available as a pyrogen free product. It is a nonhygroscopicwhite powder that readily dissolves in water. HPβCD is thermally stableand does not degrade at neutral pH. Thus, cyclodextrins improve thesolubility of a therapeutic agent in a composition. Accordingly, in someembodiments, cyclodextrins are included to increase the solubility ofthe auris-acceptable otic structure modulating agent or innate immunesystem modulating agents within the compositions described herein. Inother embodiments, cyclodextrins in addition serve as controlled-releaseexcipients within the compositions described herein.

By way of example only, cyclodextrin derivatives for use includeα-cyclodextrin, β-cyclodextrin, γ-cyclodextrin, hydroxyethylβ-cyclodextrin, hydroxypropyl γ-cyclodextrin, sulfated β-cyclodextrin,sulfated α-cyclodextrin, sulfobutyl ether β-cyclodextrin.

The concentration of the cyclodextrin used in the compositions andmethods disclosed herein varies according to the physiochemicalproperties, pharmacokinetic properties, side effect or adverse events,composition considerations, or other factors associated with thetherapeutically active agent, or a salt or prodrug thereof, or with theproperties of other excipients in the composition. Thus, in certaincircumstances, the concentration or amount of cyclodextrin used inaccordance with the compositions and methods disclosed herein will vary,depending on the need. When used, the amount of cyclodextrins needed toincrease solubility of the otic structure modulating agent or innateimmune system modulating agent and/or function as a controlled-releaseexcipient in any of the compositions described herein is selected usingthe principles, examples, and teachings described herein.

Other stabilizers that are useful in the auris-acceptable compositionsdisclosed herein include, for example, fatty acids, fatty alcohols,alcohols, long chain fatty acid esters, long chain ethers, hydrophilicderivatives of fatty acids, polyvinyl pyrrolidones, polyvinyl ethers,polyvinyl alcohols, hydrocarbons, hydrophobic polymers,moisture-absorbing polymers, and combinations thereof. In someembodiments, amide analogues of stabilizers are also used. In furtherembodiments, the chosen stabilizer changes the hydrophobicity of thecomposition (e.g., oleic acid, waxes), or improves the mixing of variouscomponents in the composition (e.g., ethanol), controls the moisturelevel in the formula (e.g., PVP or polyvinyl pyrrolidone), controls themobility of the phase (substances with melting points higher than roomtemperature such as long chain fatty acids, alcohols, esters, ethers,amides etc. or mixtures thereof, waxes), and/or improves thecompatibility of the formula with encapsulating materials (e.g., oleicacid or wax). In another embodiment some of these stabilizers are usedas solvents/co-solvents (e.g., ethanol). In other embodiments,stabilizers are present in sufficient amounts to inhibit the degradationof the otic structure modulating agent or innate immune systemmodulating agent. Examples of such stabilizing agents, include, but arenot limited to: (a) about 0.5% to about 2% w/v glycerol, (b) about 0.1%to about 1% w/v methionine, (c) about 0.1% to about 2% w/vmonothioglycerol, (d) about 1 mM to about 10 mM EDTA, (e) about 0.01% toabout 2% w/v ascorbic acid, (f) 0.003% to about 0.02% w/v polysorbate80, (g) 0.001% to about 0.05% w/v. polysorbate 20, (h) arginine, (i)heparin, (j) dextran sulfate, (k) cyclodextrins, (l) pentosanpolysulfate and other heparinoids, (m) divalent cations such asmagnesium and zinc; or (n) combinations thereof.

Additional useful otic structure modulating agent or innate immunesystem modulating agent auris-acceptable compositions include one ormore anti-aggregation additives to enhance stability of a otic structuremodulating compositions by reducing the rate of protein aggregation. Theanti-aggregation additive selected depends upon the nature of theconditions to that the otic structure modulating agent or innate immunesystem modulating agents, for example otic structure modulating agent orinnate immune system modulating agent antibodies are exposed. Forexample, certain compositions undergoing agitation and thermal stressrequire a different anti-aggregation additive than a compositionundergoing lyophilization and reconstitution. Useful anti-aggregationadditives include, by way of example only, urea, guanidinium chloride,simple amino acids such as glycine or arginine, sugars, polyalcohols,polysorbates, polymers such as polyethylene glycol and dextrans, alkylsaccharides, such as alkyl glycoside, and surfactants.

Other useful compositions optionally include one or moreauris-acceptable antioxidants to enhance chemical stability whererequired. Suitable antioxidants include, by way of example only,ascorbic acid, methionine, sodium thiosulfate and sodium metabisulfite.In one embodiment, antioxidants are selected from metal chelatingagents, thiol containing compounds and other general stabilizing agents.

Still other useful compositions include one or more auris-acceptablesurfactants to enhance physical stability or for other purposes.Suitable nonionic surfactants include, but are not limited to,polyoxyethylene fatty acid glycerides and vegetable oils, e.g.,polyoxyethylene (60) hydrogenated castor oil; and polyoxyethylenealkylethers and alkylphenyl ethers, e.g., octoxynol 10, octoxynol 40.

In some embodiments, the auris-acceptable pharmaceutical compositionsdescribed herein are stable with respect to compound degradation over aperiod of any of at least about 1 day, at least about 2 days, at leastabout 3 days, at least about 4 days, at least about 5 days, at leastabout 6 days, at least about 1 week, at least about 2 weeks, at leastabout 3 weeks, at least about 4 weeks, at least about 5 weeks, at leastabout 6 weeks, at least about 7 weeks, at least about 8 weeks, at leastabout 3 months, at least about 4 months, at least about 5 months, or atleast about 6 months. In other embodiments, the compositions describedherein are stable with respect to compound degradation over a period ofat least about 1 week. Also described herein are compositions that arestable with respect to compound degradation over a period of at leastabout 1 month.

In other embodiments, an additional surfactant (co-surfactant) and/orbuffering agent is combined with one or more of the pharmaceuticallyacceptable vehicles previously described herein so that the surfactantand/or buffering agent maintains the product at an optimal pH forstability. Suitable co-surfactants include, but are not limited to: a)natural and synthetic lipophilic agents, e.g., phospholipids,cholesterol, and cholesterol fatty acid esters and derivatives thereof,b) nonionic surfactants, which include for example, polyoxyethylenefatty alcohol esters, sorbitan fatty acid esters (Spans),polyoxyethylene sorbitan fatty acid esters (e.g., polyoxyethylene (20)sorbitan monooleate (Tween 80), polyoxyethylene (20) sorbitanmonostearate (Tween 60), polyoxyethylene (20) sorbitan monolaurate(Tween 20) and other Tweens, sorbitan esters, glycerol esters, e.g.,Myrj and glycerol triacetate (triacetin), polyethylene glycols, cetylalcohol, cetostearyl alcohol, stearyl alcohol, polysorbate 80,poloxamers, poloxamines, polyoxyethylene castor oil derivatives (e.g.,Cremophor® RH40, Cremphor A25, Cremphor A20, Cremophor® EL) and otherCremophors, sulfosuccinates, alkyl sulphates (SLS); PEG glyceryl fattyacid esters such as PEG-8 glyceryl caprylate/caprate (Labrasol), PEG-4glyceryl caprylate/caprate (Labrafac Hydro WL 1219), PEG-32 glyceryllaurate (Gelucire 444/14), PEG-6 glyceryl mono oleate (Labrafil M 1944CS), PEG-6 glyceryl linoleate (Labrafil M 2125 CS); propylene glycolmono- and di-fatty acid esters, such as propylene glycol laurate,propylene glycol caprylate/caprate; Brij® 700, ascorbyl-6-palmitate,stearylamine, sodium lauryl sulfate, polyoxethyleneglyceroltriiricinoleate, and any combinations or mixtures thereof; c) anionicsurfactants include, but are not limited to, calciumcarboxymethylcellulose, sodium carboxymethylcellulose, sodiumsulfosuccinate, dioctyl, sodium alginate, alkyl polyoxyethylenesulfates, sodium lauryl sulfate, triethanolamine stearate, potassiumlaurate, bile salts, and any combinations or mixtures thereof, and d)cationic surfactants such as cetyltrimethylammonium bromide, andlauryldimethylbenzyl-ammonium chloride.

In a further embodiment, when one or more co-surfactants are utilized inthe auris-acceptable compositions of the present disclosure, they arecombined, e.g., with a pharmaceutically acceptable vehicle and ispresent in the final composition, e.g., in an amount ranging from about0.1% to about 20%, from about 0.5% to about 10%.

In one embodiment, the surfactant has an HLB value of 0 to 20. Inadditional embodiments, the surfactant has an HLB value of 0 to 3, of 4to 6, of 7 to 9, of 8 to 18, of 13 to 15, of 10 to 18.

In one embodiment, diluents are also used to stabilize the oticstructure modulating agent or innate immune system modulating agent orother pharmaceutical compounds because they provide a more stableenvironment. Salts dissolved in buffered solutions (that also canprovide pH control or maintenance) are utilized as diluents, including,but not limited to a phosphate buffered saline solution. In otherembodiments, the gel composition is isotonic with the endolymph or theperilymph: depending on the portion of the cochlea that the oticstructure modulating agent or innate immune system modulating agentcomposition is targeted. Isotonic compositions are provided by theaddition of a tonicity agent. Suitable tonicity agents include, but arenot limited to any pharmaceutically acceptable sugar, salt or anycombinations or mixtures thereof, such as, but not limited to dextroseand sodium chloride. In further embodiments, the tonicity agents arepresent in an amount from about 100 mOsm/kg to about 500 mOsm/kg. Insome embodiments, the tonicity agent is present in an amount from about200 mOsm/kg to about 400 mOsm/kg, from about 280 mOsm/kg to about 320mOsm/kg. The amount of tonicity agents will depend on the targetstructure of the pharmaceutical composition, as described herein.

Useful tonicity compositions also include one or more salts in an amountrequired to bring osmolality of the composition into an acceptable rangefor the perilymph or the endolymph. Such salts include those havingsodium, potassium or ammonium cations and chloride, citrate, ascorbate,borate, phosphate, bicarbonate, sulfate, thiosulfate or bisulfiteanions; suitable salts include sodium chloride, potassium chloride,sodium thiosulfate, sodium bisulfite and ammonium sulfate.

In some embodiments, the auris-acceptable gel compositions disclosedherein alternatively or additionally contains preservatives to preventmicrobial growth. Suitable auris-acceptable preservatives for use in theenhanced viscosity compositions described herein include, but are notlimited to benzoic acid, boric acid, p-hydroxybenzoates, alcohols,quarternary compounds, stabilized chlorine dioxide, mercurials, such asmerfen and thiomersal, mixtures of the foregoing and the like.

In a further embodiment, the preservative is, by way of example only, anantimicrobial agent, within the auris-acceptable compositions presentedherein. In one embodiment, the composition includes a preservative suchas by way of example only, methyl paraben, sodium bisulfite, sodiumthiosulfate, ascorbate, chorobutanol, thimerosal, parabens, benzylalcohol, phenylethanol and others. In another embodiment, the methylparaben is at a concentration of about 0.05% to about 1.0%, about 0.1%to about 0.2%. In a further embodiment, the gel is prepared by mixingwater, methylparaben, hydroxyethylcellulose and sodium citrate. In afurther embodiment, the gel is prepared by mixing water, methylparaben,hydroxyethylcellulose and sodium acetate. In a further embodiment, themixture is sterilized by autoclaving at 120° C. for about 20 minutes,and tested for pH, methylparaben concentration and viscosity beforemixing with the appropriate amount of the otic structure modulatingagent or innate immune system modulating agent disclosed herein.

Suitable auris-acceptable water soluble preservatives that are employedin the drug delivery vehicle include sodium bisulfite, sodiumthiosulfate, ascorbate, chorobutanol, thimerosal, parabens, benzylalcohol, Butylated hydroxytoluene (BHT), phenylethanol and others. Theseagents are present, generally, in amounts of about 0.001% to about 5% byweight or, in the amount of about 0.01 to about 2% by weight. In someembodiments, auris-compatible compositions described herein are free ofpreservatives.

Round Window Membrane Penetration Enhancers

In another embodiment, the composition further comprises one or moreround window membrane penetration enhancers. Penetration across theround window membrane is enhanced by the presence of round windowmembrane penetration enhancers. Round window membrane penetrationenhancers are chemical entities that facilitate transport ofcoadministered substances across the round window membrane. Round windowmembrane penetration enhancers are grouped according to chemicalstructure. Surfactants, both ionic and non-ionic, such as sodium laurylsulfate, sodium laurate, polyoxyethylene-20-cetyl ether, laureth-9,sodium dodecylsulfate, dioctyl sodium sulfosuccinate,polyoxyethylene-9-lauryl ether (PLE), Tween® 80,nonylphenoxypolyethylene (NP—POE), polysorbates and the like, functionas round window membrane penetration enhancers. Bile salts (such assodium glycocholate, sodium deoxycholate, sodium taurocholate, sodiumtaurodihydrofusidate, sodium glycodihydrofusidate and the like), fattyacids and derivatives (such as oleic acid, caprylic acid, mono- anddi-glycerides, lauric acids, acylcholines, caprylic acids,acylcarnitines, sodium caprates and the like), chelating agents (such asEDTA, citric acid, salicylates and the like), sulfoxides (such asdimethyl sulfoxide (DMSO), decylmethyl sulfoxide and the like), andalcohols (such as ethanol, isopropanol, glycerol, propanediol and thelike) also function as round window membrane penetration enhancers.

In some embodiments, the auris acceptable penetration enhancer is asurfactant comprising an alkyl-glycoside wherein the alkyl glycoside istetradecyl-β-D-maltoside. In some embodiments, the auris acceptablepenetration enhancer is a surfactant comprising an alkyl-glycosidewherein the alkyl glycoside is dodecyl-maltoside. In certain instances,the penetration enhancing agent is a hyaluronidase. In certaininstances, a hyaluronidase is a human or bovine hyaluronidase. In someinstances, a hyaluronidase is a human hyaluronidase (e.g., hyaluronidasefound in human sperm, PH20 (Halozyme), Hyelenex® (Baxter International,Inc.)). In some instances, a hyaluronidase is a bovine hyaluronidase(e.g., bovine testicular hyaluronidase, Amphadase® (AmphastarPharmaceuticals), Hydase® (PrimaPharm, Inc). In some instances, ahyaluronidase is an ovine hyaluronidase, Vitrase® (ISTAPharmaceuticals). In certain instances, a hyaluronidase described hereinis a recombinant hyaluronidase. In some instances, a hyaluronidasedescribed herein is a humanized recombinant hyaluronidase. In someinstances, a hyaluronidase described herein is a pegylated hyaluronidase(e.g., PEGPH20 (Halozyme)). In addition, the peptide-like penetrationenhancers described in U.S. Pat. Nos. 7,151,191, 6,221,367 and5,714,167, herein incorporated by references for such disclosure, arecontemplated as an additional embodiment. These penetration enhancersare amino-acid and peptide derivatives and enable drug absorption bypassive transcellular diffusion without affecting the integrity ofmembranes or intercellular tight junctions.

Round Window Membrane Permeable Liposomes

Liposomes or lipid particles may also be employed to encapsulate theotic structure modulating compositions or compositions. Phospholipidsthat are gently dispersed in an aqueous medium form multilayer vesicleswith areas of entrapped aqueous media separating the lipid layers.Sonication, or turbulent agitation, of these multilayer vesicles resultsin the formation of single layer vesicles, commonly referred to asliposomes, with sizes of about 10-1000 nm. These liposomes have manyadvantages as otic structure modulating agent or innate immune systemmodulating agents or other pharmaceutical agent carriers. They arebiologically inert, biodegradable, non-toxic and non-antigenic.Liposomes are formed in various sizes and with varying compositions andsurface properties. Additionally, they are able to entrap a wide varietyof agents and release the agent at the site of liposome collapse.

Suitable phospholipids for use in auris-acceptable liposomes here are,for example, phosphatidyl cholines, ethanolamines and serines,sphingomyelins, cardiolipins, plasmalogens, phosphatidic acids andcerebrosides, in particular those that are soluble together with theotic structure modulating agent or innate immune system modulatingagents herein in non-toxic, pharmaceutically acceptable organicsolvents. Preferred phospholipids are, for example, phosphatidylcholine, phosphatidyl ethanolmine, phosphatidyl serine, phosphatidylinositol, lysophosphatidyl choline, phosphatidyl glycerol and the like,and mixtures thereof especially lecithin, e.g. soya lecithin. The amountof phospholipid used in the present composition range from about 10 toabout 30%, preferably from about 15 to about 25% and in particular isabout 20%.

Lipophilic additives may be employed advantageously to modifyselectively the characteristics of the liposomes. Examples of suchadditives include by way of example only, stearylamine, phosphatidicacid, tocopherol, cholesterol, cholesterol hemisuccinate and lanolinextracts. The amount of lipophilic additive used range from 0.5 to 8%,preferably from 1.5 to 4% and in particular is about 2%. Generally, theratio of the amount of lipophilic additive to the amount of phospholipidranges from about 1:8 to about 1:12 and in particular is about 1:10.Said phospholipid, lipophilic additive and the otic structure modulatingagent or innate immune system modulating agent and other pharmaceuticalcompounds are employed in conjunction with a non-toxic, pharmaceuticallyacceptable organic solvent system that dissolve said ingredients. Saidsolvent system not only must dissolve the otic structure modulatingagent or innate immune system modulating agent completely, but it alsohas to allow the composition of stable single bilayered liposomes. Thesolvent system comprises dimethylisosorbide and tetraglycol (glycofurol,tetrahydrofurfuryl alcohol polyethylene glycol ether) in an amount ofabout 8 to about 30%. In said solvent system, the ratio of the amount ofdimethylisosorbide to the amount of tetraglycol range from about 2:1 toabout 1:3, in particular from about 1:1 to about 1:2.5 and preferably isabout 1:2. The amount of tetraglycol in the final composition thus varyfrom 5 to 20%, in particular from 5 to 15% and preferably isapproximately 10%. The amount of dimethylisosorbide in the finalcomposition thus range from 3 to 10%, in particular from 3 to 7% andpreferably is approximately 5%.

The term “organic component” as used hereinafter refers to mixturescomprising said phospholipid, lipophilic additives and organic solvents.The otic structure modulating agent or innate immune system modulatingagent may be dissolved in the organic component, or other means tomaintain full activity of the agent. The amount of an otic structuremodulating agent or innate immune system modulating agent in the finalcomposition may range from 0.1 to 5.0%. In addition, other ingredientssuch as anti-oxidants may be added to the organic component. Examplesinclude tocopherol, butylated hydroxyanisole, butylated hydroxytoluene,ascorbyl palmitate, ascorbyl oleate and the like.

Liposomal compositions are alternatively prepared, for otic structuremodulating agent or innate immune system modulating agents or otherpharmaceutical agents that are moderately heat-resistant, by (a) heatingthe phospholipid and the organic solvent system to about 60-80° C. in avessel, dissolving the active ingredient, then adding any additionalformulating agents, and stirring the mixture until complete dissolutionis obtained; (b) heating the aqueous solution to 90-95° C. in a secondvessel and dissolving the preservatives therein, allowing the mixture tocool and then adding the remainder of the auxiliary formulating agentsand the remainder of the water, and stirring the mixture until completedissolution is obtained; thus preparing the aqueous component; (c)transferring the organic phase directly into the aqueous component,while homogenizing the combination with a high performance mixingapparatus, for example, a high-shear mixer; and (d) adding a viscosityenhancing agent to the resulting mixture while further homogenizing. Theaqueous component is optionally placed in a suitable vessel that isequipped with a homogenizer and homogenization is effected by creatingturbulence during the injection of the organic component. Any mixingmeans or homogenizer that exerts high shear forces on the mixture may beemployed. Generally, a mixer capable of speeds from about 1,500 to20,000 rpm, in particular from about 3,000 to about 6,000 rpm may beemployed. Suitable viscosity enhancing agents for use in process step(d) are for example, xanthan gum, hydroxypropyl cellulose, hydroxypropylmethylcellulose or mixtures thereof. The amount of viscosity enhancingagent depends on the nature and the concentration of the otheringredients and in general ranges from about 0.5 to 2.0%, orapproximately 1.5%. In order to prevent degradation of the materialsused during the preparation of the liposomal composition, it isadvantageous to purge all solutions with an inert gas such as nitrogenor argon, and to conduct all steps under an inert atmosphere. Liposomesprepared by the above described method usually contain most of theactive ingredient bound in the lipid bilayer and separation of theliposomes from unencapsulated material is not required.

In other embodiments, the auris-acceptable compositions, including gelcompositions and viscosity-enhanced compositions, further includeexcipients, other medicinal or pharmaceutical agents, carriers,adjuvants, such as preserving, stabilizing, wetting or emulsifyingagents, solution promoters, salts, solubilizers, an antifoaming agent,an antioxidant, a dispersing agent, a wetting agent, a surfactant, andcombinations thereof.

Suitable carriers for use in an auris-acceptable composition describedherein include, but are not limited to, any pharmaceutically acceptablesolvent compatible with the targeted auris structure's physiologicalenvironment. In other embodiments, the base is a combination of apharmaceutically acceptable surfactant and solvent.

In some embodiments, other excipients include, sodium stearyl fumarate,diethanolamine cetyl sulfate, isostearate, polyethoxylated castor oil,nonoxyl 10, octoxynol 9, sodium lauryl sulfate, sorbitan esters(sorbitan monolaurate, sorbitan monooleate, sorbitan monopalmitate,sorbitan monostearate, sorbitan sesquioleate, sorbitan trioleate,sorbitan tristearate, sorbitan laurate, sorbitan oleate, sorbitanpalmitate, sorbitan stearate, sorbitan dioleate, sorbitansesqui-isostearate, sorbitan sesquistearate, sorbitan tri-isostearate),lecithin pharmaceutical acceptable salts thereof and combinations ormixtures thereof.

In other embodiments, the carrier is a polysorbate. Polysorbates arenonionic surfactants of sorbitan esters. Polysorbates useful in thepresent disclosure include, but are not limited to polysorbate 20,polysorbate 40, polysorbate 60, polysorbate 80 (Tween 80) and anycombinations or mixtures thereof. In further embodiments, polysorbate 80is utilized as the pharmaceutically acceptable carrier.

In one embodiment, water-soluble glycerin-based auris-acceptableenhanced viscosity compositions utilized in the preparation ofpharmaceutical delivery vehicles comprise an otic structure modulatingagent or innate immune system modulating agent containing at least about0.1% of the water-soluble glycerin compound or more. In someembodiments, the percentage of an otic structure modulating agent orinnate immune system modulating agent is varied between about 1% andabout 95%, between about 5% and about 80%, between about 10% and about60% or more of the weight or volume of the total pharmaceuticalcomposition. In some embodiments, the amount of the compound(s) in eachtherapeutically useful otic structure modulating agent or innate immunesystem modulating agent composition is prepared in such a way that asuitable dosage will be obtained in any given unit dose of the compound.Factors such as solubility, bioavailability, biological half-life, routeof administration, product shelf life, as well as other pharmacologicalconsiderations are contemplated herein.

If desired, the auris-acceptable pharmaceutical gels also containco-solvents, preservatives, cosolvents, ionic strength and osmolalityadjustors and other excipients in addition to buffering agents. Suitableauris-acceptable water soluble buffering agents are alkali or alkalineearth metal carbonates, phosphates, bicarbonates, citrates, borates,acetates, succinates and the like, such as sodium phosphate, citrate,borate, acetate, bicarbonate, carbonate and tromethamine (TRIS). Theseagents are present in amounts sufficient to maintain the pH of thesystem at 7.4±0.2 and preferably, 7.4. As such, the buffering agent isas much as 5% on a weight basis of the total composition.

Cosolvents are used to enhance otic structure modulating agent or innateimmune system modulating agent solubility, however, some otic structuremodulating agent or innate immune system modulating agents or otherpharmaceutical compounds are insoluble. These are often suspended in thepolymer vehicle with the aid of suitable suspending or viscosityenhancing agents.

Moreover, some pharmaceutical excipients, diluents or carriers arepotentially ototoxic. For example, benzalkonium chloride, a commonpreservative, is ototoxic and therefore potentially harmful ifintroduced into the vestibular or cochlear structures. In formulating acontrolled-release otic structure modulating agent or innate immunesystem modulating agent composition, it is advised to avoid or combinethe appropriate excipients, diluents or carriers to lessen or eliminatepotential ototoxic components from the composition, or to decrease theamount of such excipients, diluents or carriers. Optionally, acontrolled-release otic structure modulating agent or innate immunesystem modulating agent composition includes otoprotective agents, suchas antioxidants, alpha lipoic acid, calcium, fosfomycin or ironchelators, to counteract potential ototoxic effects that may arise fromthe use of specific therapeutic agents or excipients, diluents orcarriers.

The following are examples of therapeutically acceptable oticcompositions:

Example Composition Example Characteristics Chitosan tunable degradationof matrix in vitro glycerophosphate (CGP) tunable TACE inhibitor releasein vitro: e.g., ~50% of drug released after 24 hrs biodegradablecompatible with drug delivery to the inner ear suitable formacromolecules and hydrophobic drugs PEG-PLGA-PEG triblock tunable highstability: e.g., maintains mechanical integrity polymers >1 month invitro tunable fast release of hydrophilic drugs: e.g., ~50% of drugreleased after 24 hrs, and remainder released over ~5 days tunable slowrelease of hydrophobic drugs: e.g., ~80% released after 8 weeksbiodegradable subcutaneous injection of solution: e.g., gel forms withinseconds and is intact after 1 month PEO-PPO-PEO triblock Tunable sol-geltransition temperature: e.g., decreases copolymers (e.g., withincreasing F127 concentration Pluronic or Poloxameres) (e.g., F127)Chitosan CGP composition tolerates liposomes: e.g., up to 15 uM/mlglycerophosphate with liposomes. drug-loaded liposomes liposomes tunablyreduce drug release time (e.g., up to 2 weeks in vitro). increase inliposome diameter optionally reduces drug release kinetics (e.g.,liposome size between 100 and 300 nm) release parameters are controlledby changing composition of liposomes

The compositions disclosed herein alternatively encompass anotoprotectant agent in addition to the at least one active agent and/orexcipients, including but not limited to such agents as antioxidants,alpha lipoic acid, calcium, fosfomycin or iron chelators, to counteractpotential ototoxic effects that may arise from the use of specifictherapeutic agents or excipients, diluents or carriers.

Modes of Treatment

Dosing Methods and Schedules

Drugs delivered to the inner ear have been administered systemically viaoral, intravenous or intramuscular routes. However, systemicadministration for pathologies local to the inner ear increases thelikelihood of systemic toxicities and adverse side effects and creates anon-productive distribution of drug in that high levels of drug arefound in the serum and correspondingly lower levels are found at theinner ear.

Intratympanic injection of therapeutic agents is the technique ofinjecting a therapeutic agent behind the tympanic membrane into themiddle and/or inner ear. In one embodiment, the compositions describedherein are administered directly onto the round window membrane viatranstympanic injection. In another embodiment, the otic structuremodulating agent or innate immune system modulating agentauris-acceptable compositions described herein are administered onto theround window membrane via a non-transtympanic approach to the inner ear.In additional embodiments, the composition described herein isadministered onto the round window membrane via a surgical approach tothe round window membrane comprising modification of the cristafenestrae cochleae.

In one embodiment the delivery system is a syringe and needle apparatusthat is capable of piercing the tympanic membrane and directly accessingthe round window membrane or crista fenestrae cochleae of the aurisinterna. In some embodiments, the needle on the syringe is wider than a18 gauge needle. In another embodiment, the needle gauge is from 18gauge to 31 gauge. In a further embodiment, the needle gauge is from 25gauge to 30 gauge. Depending upon the thickness or viscosity of the oticstructure modulating compositions or compositions, the gauge level ofthe syringe or hypodermic needle may be varied accordingly. In anotherembodiment, the internal diameter of the needle can be increased byreducing the wall thickness of the needle (commonly referred as thinwall or extra thin wall needles) to reduce the possibility of needleclogging while maintaining an adequate needle gauge.

In another embodiment, the needle is a hypodermic needle used forinstant delivery of the gel composition. The hypodermic needle may be asingle use needle or a disposable needle. In some embodiments, a syringemay be used for delivery of the pharmaceutically acceptable gel-basedotic structure modulating agent or innate immune system modulatingagent-containing compositions as disclosed herein wherein the syringehas a press-fit (Luer) or twist-on (Luer-lock) fitting. In oneembodiment, the syringe is a hypodermic syringe. In another embodiment,the syringe is made of plastic or glass. In yet another embodiment, thehypodermic syringe is a single use syringe. In a further embodiment, theglass syringe is capable of being sterilized. In yet a furtherembodiment, the sterilization occurs through an autoclave. In anotherembodiment, the syringe comprises a cylindrical syringe body wherein thegel composition is stored before use. In other embodiments, the syringecomprises a cylindrical syringe body wherein the otic structuremodulating agent or innate immune system modulating agentpharmaceutically acceptable gel-based compositions as disclosed hereinis stored before use that conveniently allows for mixing with a suitablepharmaceutically acceptable buffer. In other embodiments, the syringemay contain other excipients, stabilizers, suspending agents, diluentsor a combination thereof to stabilize or otherwise stably store the oticstructure modulating agent or innate immune system modulating agent orother pharmaceutical compounds contained therein.

In some embodiments, the syringe comprises a cylindrical syringe bodywherein the body is compartmentalized in that each compartment is ableto store at least one component of the auris-acceptable otic structuremodulating agent or innate immune system modulating agent gelcomposition. In a further embodiment, the syringe having acompartmentalized body allows for mixing of the components prior toinjection into the auris media or auris interna. In other embodiments,the delivery system comprises multiple syringes, each syringe of themultiple syringes contains at least one component of the gel compositionsuch that each component is pre-mixed prior to injection or is mixedsubsequent to injection. In a further embodiment, the syringes disclosedherein comprise at least one reservoir wherein the at least onereservoir comprises an otic structure modulating agent or innate immunesystem modulating agent, or a pharmaceutically acceptable buffer, or aviscosity enhancing agent, such as a gelling agent or a combinationthereof. Commercially available injection devices are optionallyemployed in their simplest form as ready-to-use plastic syringes with asyringe barrel, needle assembly with a needle, plunger with a plungerrod, and holding flange, to perform an intratympanic inj ection.

In some embodiments, the delivery device is an apparatus designed foradministration of therapeutic agents to the middle and/or inner ear. Byway of example only: GYRUS Medical Gmbh offers micro-otoscopes forvisualization of and drug delivery to the round window niche; Arenberghas described a medical treatment device to deliver fluids to inner earstructures in U.S. Pat. Nos. 5,421,818; 5,474,529; and 5,476,446, eachof that is incorporated by reference herein for such disclosure. U.S.patent application Ser. No. 08/874,208, which is incorporated herein byreference for such disclosure, describes a surgical method forimplanting a fluid transfer conduit to deliver therapeutic agents to theinner ear. U.S. Patent Application Publication 2007/0167918, which isincorporated herein by reference for such disclosure, further describesa combined otic aspirator and medication dispenser for intratympanicfluid sampling and medicament application.

The compositions described herein, and modes of administration thereof,are also applicable to methods of direct instillation or perfusion ofthe inner ear compartments. Thus, the compositions described herein areuseful in surgical procedures including, by way of non-limitingexamples, cochleostomy, labyrinthotomy, mastoidectomy, stapedectomy,endolymphatic sacculotomy or the like.

The auris-acceptable compositions or compositions containing the oticstructure modulating agent or innate immune system modulating agentcompound(s) described herein are administered for prophylactic and/ortherapeutic treatments. In therapeutic applications, the otic structuremodulating compositions are administered to a patient already sufferingfrom a disorder disclosed herein, in an amount sufficient to cure or atleast partially arrest the symptoms of the disease, disorder orcondition. Amounts effective for this use will depend on the severityand course of the disease, disorder or condition, previous therapy, thepatient's health status and response to the drugs, and the judgment ofthe treating physician.

In the case wherein the patient's condition does not improve, upon thedoctor's discretion the administration of the otic structure modulatingagent or innate immune system modulating agent compounds may beadministered chronically, which is, for an extended period of time,including throughout the duration of the patient's life in order toameliorate or otherwise control or limit the symptoms of the patient'sdisease or condition.

In the case wherein the patient's status does improve, upon the doctor'sdiscretion the administration of the otic structure modulating agent orinnate immune system modulating agent compounds may be givencontinuously; alternatively, the dose of drug being administered may betemporarily reduced or temporarily suspended for a certain length oftime (i.e., a “drug holiday”). The length of the drug holiday variesbetween 2 days and 1 year, including by way of example only, 2 days, 3days, 4 days, 5 days, 6 days, 7 days, 10 days, 12 days, 15 days, 20days, 28 days, 35 days, 50 days, 70 days, 100 days, 120 days, 150 days,180 days, 200 days, 250 days, 280 days, 300 days, 320 days, 350 days,and 365 days. The dose reduction during a drug holiday may be from10%-100%, including by way of example only 10%, 15%, 20%, 25%, 30%, 35%,40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, and 100%.

Once improvement of the patient's otic conditions has occurred, amaintenance otic structure modulating agent or innate immune systemmodulating agent dose is administered if necessary. Subsequently, thedosage or the frequency of administration, or both, is optionallyreduced, as a function of the symptoms, to a level at that the improveddisease, disorder or condition is retained. In certain embodiments,patients require intermittent treatment on a long-term basis upon anyrecurrence of symptoms.

The amount of an otic structure modulating agent or innate immune systemmodulating agent that will correspond to such an amount will varydepending upon factors such as the particular compound, diseasecondition and its severity, according to the particular circumstancessurrounding the case, including, e.g., the specific otic structuremodulating agent or innate immune system modulating agent beingadministered, the route of administration, the condition being treated,the target area being treated, and the subject or host being treated. Ingeneral, however, doses employed for adult human treatment willtypically be in the range of 0.02-50 mg per administration, preferably1-15 mg per administration. The desired dose is presented in a singledose or as divided doses administered simultaneously (or over a shortperiod of time) or at appropriate intervals.

In some embodiments, the initial administration is a particular oticstructure modulating agent or innate immune system modulating agent andthe subsequent administration a different composition or otic structuremodulating agent or innate immune system modulating agent.

Implants of Exogenous Materials

In some embodiments, the pharmaceutical formulations, compositions anddevices described herein are used in combination with (e.g.,implantation, short-term use, long-term use, or removal of) theimplantation of an exogenous material (e.g., a medical device or aplurality of cells (e.g., stem cells)). As used herein, the term“exogenous material” includes auris-interna or auris-media medicaldevices (e.g., hearing sparing devices, hearing improving devices, shortelectrodes, micro-prostheses or piston-like prostheses); needles; drugdelivery devices, and cells (e.g., stem cells). In some instances, theimplants of exogenous materials are used in conjunction with a patientexperiencing hearing loss. In some instances, the hearing loss ispresent at birth. In some instances, the hearing loss is associated withconditions that develop or progress after birth (e.g., Merniere'sdisease) resulting in osteoneogenesis, nerve damage, obliteration ofcochlear structures, or combinations thereof.

In some instances, the exogenous material is a plurality of cells. Insome instances, the exogenous material is a plurality of stem cells.

In some instances, the exogenous material is an electronic device. Insome embodiments, the electronic device has an external portion placedbehind the ear, and a second portion that is surgically placed under theskin that helps provide a sense of sound to a person who is profoundlydeaf or severely hard-of-hearing. By way of example only, such medicaldevice implants bypass damaged portions of the ear and directlystimulate the auditory nerve. In some instances cochlear implants areused in single sided deafness. In some instances cochlear implants areused for deafness in both ears.

In some embodiments, administration of an active agent described hereinin combination with the implantation of an exogenous material (e.g., amedical device implant or a stem cell transplant) delays or preventsdamage of auris structures, e.g., irritation, cell death osteoneogeneisand/or further neuronal degeneration, caused by installation of anexternal device and/or a plurality cells (e.g., stem cells) in the ear.In some embodiments, administration of a composition or device describedherein in combination with an implant allows for a more effectiverestoration of hearing loss compared to an implant alone.

In some embodiments, administration of an active agent described hereinreduces damage to auris structures caused by underlying conditionsallowing for successful implantation. In some embodiments,administration of an active agent described herein, in conjunctionsurgery and/or with the implantation of an exogenous material reduces orprevents negative side-effects (e.g., cell death).

In some embodiments, administration of an active agent described hereinin conjunction with the implantation of an exogenous material has atrophic effect (i.e., promotes healthy growth of cells and healing oftissue in the area of an implant or transplant). In some embodiments, atrophic effect is desirable during otic surgery or during intratympanicinjection procedures. In some embodiments, a trophic effect is desirableafter installation of a medical device or after a cell (e.g., stem cell)transplant. In some of such embodiments, the compositions or devicesdescribed herein are administered via direct cochlear injection, througha chochleostomy or via deposition on the round window

In some embodiments, administration of an active agent described hereinreduces inflammation and/or infections associated with otic surgery, orimplantation of an exogenous material (e.g., a medical device or aplurality of cells (e.g., stem cells)). In some instances, perfusion ofa surgical area with a formulation described herein reduces oreliminates post-surgical and/or post-implantation complications (e.g.,inflammation, hair cell damage, neuronal degeneration, osteoneogenesisor the like). In some instances, perfusion of a surgical area with aformulation described herein reduces post-surgery or post-implantationrecuperation time.

In one aspect, the formulations described herein, and modes ofadministration thereof, are applicable to methods of direct perfusion ofthe inner ear compartments. Thus, the formulations described herein areuseful in combination with surgical procedures including, by way ofnon-limiting examples, cochleostomy, labyrinthotomy, mastoidectomy,stapedectomy, stapedotomy, endolymphatic sacculotomy or the like. Insome embodiments, the inner ear compartments are perfused with aformulation described herein prior to otic surgery, during otic surgery,after otic surgery, or a combination thereof. In some of suchembodiments, the formulations described herein are substantially free ofextended release components (e.g., gelling components such aspolyoxyethylene-polyoxypropylene copolymers). In some of suchembodiments, the formulations described herein contain less than 5% ofthe extended release components (e.g., gelling components such aspolyoxyethylene-polyoxypropylene triblock copolymers) by weight of theformulation. In some of such embodiments, the formulations describedherein contain less than 2% of the extended release components (e.g.,gelling components such as polyoxyethylene-polyoxypropylene triblockcopolymers) by weight of the formulation. In some of such embodiments,the formulations described herein contain less than 1% of the extendedrelease components (e.g., gelling components such aspolyoxyethylene-polyoxypropylene triblock copolymers) by weight of theformulation. In some of such embodiments, a composition described hereinthat is used for perfusion of a surgical area contains substantially nogelling component.

Viscosity

In further embodiments, the auris gel formulation contains a viscosityenhancing agent sufficient to provide a viscosity of between about 500and 1,000,000 centipoise, between about 750 and 1,000,000 centipoise;between about 1000 and 1,000,000 centipoise; between about 1000 and400,000 centipoise; between about 2000 and 100,000 centipoise; betweenabout 3000 and 50,000 centipoise; between about 4000 and 25,000centipoise; between about 5000 and 20,000 centipoise; or between about6000 and 15,000 centipoise. In some embodiments, the auris gelformulation contains a viscosity enhancing agent sufficient to provide aviscosity of between about 50,0000 and 1,000,000 centipoise.

In some embodiments, the compositions or devices described herein arelow viscosity compositions or devices at body temperature. In someembodiments, low viscosity compositions or devices contain from about 1%to about 10% of a viscosity enhancing agent (e.g., gelling componentssuch as polyoxyethylene-polyoxypropylene copolymers). In someembodiments, low viscosity compositions or devices contain from about 2%to about 10% of a viscosity enhancing agent (e.g., gelling componentssuch as polyoxyethylene-polyoxypropylene copolymers). In someembodiments, low viscosity compositions or devices contain from about 5%to about 10% of a viscosity enhancing agent (e.g., gelling componentssuch as polyoxyethylene-polyoxypropylene copolymers). In someembodiments, low viscosity compositions or devices are substantiallyfree of a viscosity enhancing agent (e.g., gelling components such aspolyoxyethylene-polyoxypropylene copolymers). In some embodiments, a lowviscosity otic structure modulating or complement modulating compositionor device described herein provides an apparent viscosity of from about100 cP to about 10,000 cP. In some embodiments, a low viscosity oticstructure modulating or complement modulating composition or devicedescribed herein provides an apparent viscosity of from about 500 cP toabout 10,000 cP. In some embodiments, a low viscosity otic structuremodulating or complement modulating composition or device describedherein provides an apparent viscosity of from about 1000 cP to about10,000 cP. In some of such embodiments, a low viscosity otic structuremodulating or complement modulating composition or device isadministered in combination with an external otic intervention, e.g., asurgical procedure including but not limited to middle ear surgery,inner ear surgery, typanostomy, cochleostomy, labyrinthotomy,mastoidectomy, stapedectomy, stapedotomy, endolymphatic sacculotomy orthe like. In some of such embodiments, a low viscosity otic structuremodulating or complement modulating composition or device isadministered during an otic intervention. In other such embodiments, alow viscosity otic structure modulating or complement modulatingcomposition or device is administered before the otic intervention.

In some embodiments, the compositions or devices described herein arehigh viscosity compositions or devices at body temperature. In someembodiments, high viscosity compositions or devices contain from about10% to about 25% of a viscosity enhancing agent (e.g., gellingcomponents such as polyoxyethylene-polyoxypropylene copolymers). In someembodiments, high viscosity compositions or devices contain from about14% to about 22% of a viscosity enhancing agent (e.g., gellingcomponents such as polyoxyethylene-polyoxypropylene copolymers). In someembodiments, high viscosity compositions or devices contain from about15% to about 21% of a viscosity enhancing agent (e.g., gellingcomponents such as polyoxyethylene-polyoxypropylene copolymers). In someembodiments, a high viscosity otic structure modulating or complementmodulating composition or device described herein provides an apparentviscosity of from about 100,000 cP to about 1,000,000 cP.

In some embodiments, a high viscosity otic structure modulating orcomplement modulating composition or device described herein provides anapparent viscosity of from about 150,000 cP to about 500,000 cP. In someembodiments, a high viscosity otic structure modulating or complementmodulating composition or device described herein provides an apparentviscosity of from about 250,000 cP to about 500,000 cP. In some of suchembodiments, a high viscosity composition or device is a liquid at roomtemperature and gels at about between room temperature and bodytemperature (including an individual with a serious fever, e.g., up toabout 42° C.). In some embodiments, an otic structure modulating orcomplement modulating high viscosity composition or device isadministered as monotherapy for treatment of an otic disease orcondition described herein. In some embodiments, an otic structuremodulating or complement modulating high viscosity composition or deviceis administered in combination with an external otic intervention, e.g.,a surgical procedure including but not limited to middle ear surgery,inner ear surgery, typanostomy, cochleostomy, labyrinthotomy,mastoidectomy, stapedectomy, stapedotomy, endolymphatic sacculotomy orthe like. In some of such embodiments, a high viscosity otic structuremodulating or complement modulating composition or device isadministered after the otic intervention. In other such embodiments, ahigh viscosity otic structure modulating or complement modulatingcomposition or device is administered before the otic intervention.

Pharmacokinetics of Controlled-Release Compositions

In one embodiment, the compositions disclosed herein additionallyprovides an immediate release of an otic structure modulating agent orinnate immune system modulating agent from the composition, or within 1minute, or within 5 minutes, or within 10 minutes, or within 15 minutes,or within 30 minutes, or within 60 minutes or within 90 minutes. Inother embodiments, a therapeutically effective amount of an oticstructure modulating agent or innate immune system modulating agent isreleased from the composition immediately, or within 1 minute, or within5 minutes, or within 10 minutes, or within 15 minutes, or within 30minutes, or within 60 minutes or within 90 minutes. In certainembodiments the composition comprises an auris-pharmaceuticallyacceptable gel composition providing immediate release of an oticstructure modulating agent or innate immune system modulating agent.Additional embodiments of the composition may also include an agent thatenhances the viscosity of the compositions included herein.

In other or further embodiments, the composition provides an extendedrelease composition of an otic structure modulating agent or innateimmune system modulating agent. In certain embodiments, diffusion of anotic structure modulating agent or innate immune system modulating agentfrom the composition occurs for a time period exceeding 5 minutes, or 15minutes, or 30 minutes, or 1 hour, or 4 hours, or 6 hours, or 12 hours,or 18 hours, or 1 day, or 2 days, or 3 days, or 4 days, or 5 days, or 6days, or 7 days, or 10 days, or 12 days, or 14 days, or 18 days, or 21days, or 25 days, or 30 days, or 45 days, or 2 months or 3 months or 4months or 5 months or 6 months or 9 months or 1 year. In otherembodiments, a therapeutically effective amount of an otic structuremodulating agent or innate immune system modulating agent is releasedfrom the composition for a time period exceeding 5 minutes, or 15minutes, or 30 minutes, or 1 hour, or 4 hours, or 6 hours, or 12 hours,or 18 hours, or 1 day, or 2 days, or 3 days, or 4 days, or 5 days, or 6days, or 7 days, or 10 days, or 12 days, or 14 days, or 18 days, or 21days, or 25 days, or 30 days, or 45 days, or 2 months or 3 months or 4months or 5 months or 6 months or 9 months or 1 year.

In other embodiments, the composition provides both an immediate releaseand an extended release composition of an otic structure modulatingagent or innate immune system modulating agent. In yet otherembodiments, the composition contains a 0.25:1 ratio, or a 0.5:1 ratio,or a 1:1 ratio, or a 1:2 ratio, or a 1:3, or a 1:4 ratio, or a 1:5ratio, or a 1:7 ratio, or a 1:10 ratio, or a 1:15 ratio, or a 1:20 ratioof immediate release and extended release compositions. In a furtherembodiment the composition provides an immediate release of a first oticstructure modulating agent or innate immune system modulating agent andan extended release of a second otic structure modulating agent orinnate immune system modulating agent or other therapeutic agent. In yetother embodiments, the composition provides an immediate release andextended release composition of an otic structure modulating agent orinnate immune system modulating agent, and at least one therapeuticagent. In some embodiments, the composition provides a 0.25:1 ratio, ora 0.5:1 ratio, or a 1:1 ratio, or a 1:2 ratio, or a 1:3, or a 1:4 ratio,or a 1:5 ratio, or a 1:7 ratio, or a 1:10 ratio, or a 1:15 ratio, or a1:20 ratio of immediate release and extended release compositions of afirst otic structure modulating agent or innate immune system modulatingagent and second therapeutic agent, respectively.

In a specific embodiment the composition provides a therapeuticallyeffective amount of an otic structure modulating agent or innate immunesystem modulating agent at the site of disease with essentially nosystemic exposure. In an additional embodiment the composition providesa therapeutically effective amount of an otic structure modulating agentor innate immune system modulating agent at the site of disease withessentially no detectable systemic exposure. In other embodiments, thecomposition provides a therapeutically effective amount of an oticstructure modulating agent or innate immune system modulating agent atthe site of disease with little or no detectable systemic exposure.

The combination of immediate release, delayed release and/or extendedrelease otic structure modulating compositions or compositions may becombined with other pharmaceutical agents, as well as the excipients,diluents, stabilizers, tonicity agents and other components disclosedherein. As such, depending upon the otic structure modulating agent orinnate immune system modulating agent used, the thickness or viscositydesired, or the mode of delivery chosen, alternative aspects of theembodiments disclosed herein are combined with the immediate release,delayed release and/or extended release embodiments accordingly.

In certain embodiments, the pharmacokinetics of the otic structuremodulating compositions described herein are determined by injecting thecomposition on or near the round window membrane of a test animal(including by way of example, a guinea pig or a chinchilla). At adetermined period of time (e.g., 6 hours, 12 hours, 1 day, 2 days, 3days, 4 days, 5 days, 6 days, and 7 days for testing thepharmacokinetics of a composition over a 1 week period), the test animalis euthanized and a 5 mL sample of the perilymph fluid is tested. Theinner ear removed and tested for the presence of the otic structuremodulating agent or innate immune system modulating agent. As needed,the level of an otic structure modulating agent or innate immune systemmodulating agent is measured in other organs. In addition, the systemiclevel of the otic structure modulating agent or innate immune systemmodulating agent is measured by withdrawing a blood sample from the testanimal. In order to determine whether the composition impedes hearing,the hearing of the test animal is optionally tested.

Alternatively, an inner ear is provided (as removed from a test animal)and the migration of the otic structure modulating agent or innateimmune system modulating agent is measured. As yet another alternative,an in vitro model of a round window membrane is provided and themigration of the otic structure modulating agent or innate immune systemmodulating agent is measured.

As described herein, compositions comprising micronized otic agentsprovide extended release over a longer period of time compared tocompositions comprising non-micronized otic agents. In some instances,the micronized otic agent provides a steady supply (e.g., +/−20%) ofactive agent via slow degradation and serves as a depot for the activeagent; such a depot effect increases residence time of the otic agent inthe ear. In specific embodiments, selection of an appropriate particlesize of the active agent (e.g., micronized active agent) in combinationwith the amount of gelling agent in the composition provides tunableextended release characteristics that allow for release of an activeagent over a period of hours, days, weeks or months.

In some embodiments, the viscosity of any formulation described hereinis designed to provide a suitable rate of release from an oticcompatible gel. In some embodiments, the concentration of a thickeningagent (e.g., gelling components such as polyoxyethylene-polyoxypropylenecopolymers) allows for a tunable mean dissolution time (MDT). The MDT isinversely proportional to the release rate of an active agent from acomposition or device described herein. Experimentally, the releasedotic agent is optionally fitted to the Korsmeyer-Peppas equation

$\frac{Q}{Q_{\alpha}} = {{kt}^{n} + b}$

where Q is the amount of otic agent released at time t, Q_(α) is theoverall released amount of otic agent, k is a release constant of thenth order, n is a dimensionless number related to the dissolutionmechanism and b is the axis intercept, characterizing the initial burstrelease mechanism wherein n=1 characterizes an erosion controlledmechanism. The mean dissolution time (MDT) is the sum of differentperiods of time the drug molecules stay in the matrix before release,divided by the total number of molecules and is optionally calculatedby:

${MDT} = \frac{{nk}^{{- 1}/n}}{n + 1}$

For example, a linear relationship between the mean dissolution time(MDT) of a composition or device and the concentration of the gellingagent (e.g., poloxamer) indicates that the otic agent is released due tothe erosion of the polymer gel (e.g., poloxamer) and not via diffusion.In another example, a non-linear relationship indicates release of oticagent via a combination of diffusion and/or polymer gel degradation. Inanother example, a faster gel elimination time course of a compositionor device (a faster release of active agent) indicates lower meandissolution time (MDT). The concentration of gelling components and/oractive agent in a composition are tested to determine suitableparameters for MDT. In some embodiments, injection volumes are alsotested to determine suitable parameters for preclinical and clinicalstudies. The gel strength and concentration of the active agent affectsrelease kinetics of an otic agent from the composition. At low poloxamerconcentration, elimination rate is accelerated (MDT is lower). Anincrease in otic agent concentration in the composition or deviceprolongs residence time and/or MDT of the otic agent in the ear.

In some embodiments, the MDT for poloxamer from a composition or devicedescribed herein is at least 6 hours. In some embodiments, the MDT forpoloxamer from a composition or device described herein is at least 10hours.

In some embodiments, the MDT for an active agent from a composition ordevice described herein is from about 30 hours to about 48 hours. Insome embodiments, the MDT for an active agent from a composition ordevice described herein is from about 30 hours to about 96 hours. Insome embodiments, the MDT for an active agent from a composition ordevice described herein is from about 30 hours to about 1 week. In someembodiments, the MDT for a composition or device described herein isfrom about 1 week to about 6 weeks.

In some embodiments, the mean residence time (MRT) for an active agentin a composition or device described herein is from about 20 hours toabout 48 hours. In some embodiments, the MRT for an active agent from acomposition or device described herein is from about 20 hours to about96 hours. In some embodiments, the MRT for an active agent from acomposition or device described herein is from about 20 hours to about 1week.

In some embodiments, the MRT for an active agent is about 20 hours. Insome embodiments, the MRT for an active agent is about 30 hours. In someembodiments, the MRT for an active agent is about 40 hours. In someembodiments, the MRT for an active agent is about 50 hours. In someembodiments, the MRT for an active agent is about 60 hours. In someembodiments, the MRT for an active agent is about 70 hours. In someembodiments, the MRT for an active agent is about 80 hours.

In some embodiments, the MRT for an active agent is about 90 hours. Insome embodiments, the MRT for an active agent is about 1 week. In someembodiments, the MRT for an active agent is about 90 hours. In someembodiments, the MRT for a composition or device described herein isfrom about 1 week to about 6 weeks. In some embodiments, the MRT for anactive agent is about 1 week. In some embodiments, the MRT for an activeagent is about 2 weeks. In some embodiments, the MRT for an active agentis about 3 weeks. In some embodiments, the MRT for an active agent isabout 4 weeks. In some embodiments, the MRT for an active agent is about5 weeks. The half life of an otic agent and mean residence time of theotic agent are determined for each formulation by measurement ofconcentration of the otic agent in the perilymph using proceduresdescribed herein.

In certain embodiments, any controlled release otic formulationdescribed herein increases the exposure of an otic agent and increasesthe Area Under the Curve (AUC) in otic fluids (e.g., endolymph and/orperilymph) by about 30%, about 40%, about 50%, about 60%, about 70%,about 80% or about 90% compared to a formulation that is not acontrolled release otic formulation. In certain embodiments, anycontrolled release otic formulation described herein increases theexposure time of an otic agent and decreases the C_(max) in otic fluids(e.g., endolymph and/or perilymph) by about 40%, about 30%, about 20%,or about 10%, compared to a formulation that is not a controlled releaseotic formulation. In certain embodiments, any controlled release oticformulation described herein alters (e.g. reduces) the ratio of C_(max)to C_(min) compared to a formulation that is not a controlled releaseotic formulation. In certain embodiments, any controlled release oticformulation described herein increases the exposure of an otic agent andincreases the length of time that the concentration of an otic agent isabove C_(min) by about 30%, about 40%, about 50%, about 60%, about 70%,about 80% or about 90% compared to a formulation that is not acontrolled release otic formulation. In certain instances, controlledrelease formulations described herein delay the time to C_(max). Incertain instances, the controlled steady release of a drug prolongs thetime the concentration of the drug will stay above the C_(min). In someembodiments, auris compositions described herein prolong the residencetime of a drug in the inner ear and provide a stable drug exposureprofile. In some instances, an increase in concentration of an activeagent in the composition saturates the clearance process and allows fora more rapid and stable steady state to be reached.

In certain instances, once drug exposure (e.g., concentration in theendolymph or perilymph) of a drug reaches steady state, theconcentration of the drug in the endolymph or perilymph stays at orabout the therapeutic dose for an extended period of time (e.g., oneday, 2 days, 3 days, 4 days, 5 days, 6 days, or 1 week, 3 weeks, 6weeks, 2 months). In some embodiments, the steady state concentration ofactive agent released from a controlled release formulation describedherein is about 20 to about 50 times the steady state concentration ofan active agent released from a formulation that is not a controlledrelease formulation.

The release of an active agent from any formulation, composition ordevice described herein is optionally tunable to the desired releasecharacteristics. In some embodiments, a composition described herein isa solution that is substantially free of gelling components. In suchinstances, the composition provides essentially immediate release of anactive agent. In some of such embodiments, the composition is useful inperfusion of otic structures, e.g., during surgery.

In some embodiments, a composition described herein is a solution thatis substantially free of gelling components and comprises micronizedotic agent. In some of such embodiments, the composition providesintermediate release of an active agent from about 2 day to about 4days.

In some embodiments, a composition described herein comprises a gellingagent (e.g., poloxamer 407) and provides release of an active agent overa period of from about 1 day to about 3 days. In some embodiments, acomposition described herein comprises a gelling agent (e.g., poloxamer407) and provides release of an active agent over a period of from about1 day to about 5 days. In some embodiments, a composition describedherein comprises a gelling agent (e.g., poloxamer 407) and providesrelease of an active agent over a period of from about 2 days to about 7days.

In some embodiments, a composition described herein comprises a gellingagent (e.g., poloxamer 407) in combination with micronized otic agentand provides extended sustained release. In some embodiments, acomposition described herein comprises (a) about 14-17% of a gellingagent (e.g., poloxamer 407) and (b) a micronized otic agent; andprovides extended sustained release over a period of from about 1 weekto about 3 weeks. In some embodiments, a composition described hereincomprises (a) about 16% of a gelling agent (e.g., poloxamer 407) and (b)a micronized otic agent; and provides extended sustained release over aperiod of from about 3 weeks. In some embodiments, a compositiondescribed herein comprises (a) about 18-21% of a gelling agent (e.g.,poloxamer 407) and (b) a micronized otic agent; and provides extendedsustained release over a period of from about 3 weeks to about 6 weeks.In some embodiments, a composition described herein comprises (a) about20% of a gelling agent (e.g., poloxamer 407) and (b) a micronized oticagent; and provides extended sustained release over a period of fromabout 6 weeks. In some embodiments, the amount of gelling agent in acomposition, and the particle size of an otic agent are tunable to thedesired release profile of an otic agent from the composition.

In specific embodiments, compositions comprising micronized otic agentsprovide extended release over a longer period of time compared tocompositions comprising non-micronized otic agents. In specificembodiments, selection of an appropriate particle size of the activeagent (e.g., micronized active agent) in combination with the amount ofgelling agent in the composition provides tunable extended releasecharacteristics that allow for release of an active agent over a periodof hours, days, weeks or months.

Kits/Articles of Manufacture

The disclosure also provides kits for preventing, treating orameliorating the symptoms of a disease or disorder in a mammal. Suchkits generally will comprise one or more of the otic structuremodulating agent or innate immune system modulating agentcontrolled-release compositions or devices disclosed herein, andinstructions for using the kit. The disclosure also contemplates the useof one or more of the otic structure modulating agent or innate immunesystem modulating agent controlled-release compositions, in themanufacture of medicaments for treating, abating, reducing, orameliorating the symptoms of a disease, dysfunction, or disorder in amammal, such as a human that has, is suspected of having, or at risk fordeveloping an inner ear disorder.

In some embodiments, kits include a carrier, package, or container thatis compartmentalized to receive one or more containers such as vials,tubes, and the like, each of the container(s) including one of theseparate elements to be used in a method described herein. Suitablecontainers include, for example, bottles, vials, syringes, and testtubes. In other embodiments, the containers are formed from a variety ofmaterials such as glass or plastic.

The articles of manufacture provided herein contain packaging materials.Packaging materials for use in packaging pharmaceutical products arealso presented herein. See, e.g., U.S. Pat. Nos. 5,323,907, 5,052,558and 5,033,252. Examples of pharmaceutical packaging materials include,but are not limited to, blister packs, bottles, tubes, inhalers, pumps,bags, vials, containers, syringes, bottles, and any packaging materialsuitable for a selected composition and intended mode of administrationand treatment. A wide array of a otic structure modulating compositionsprovided herein are contemplated as are a variety of treatments for anydisease, disorder, or condition that would benefit by controlled-releaseadministration of an otic structure modulating agent or innate immunesystem modulating agent to the inner ear.

In some embodiments, a kit includes one or more additional containers,each with one or more of various materials (such as reagents, optionallyin concentrated form, and/or devices) desirable from a commercial anduser standpoint for use of a composition described herein. Non-limitingexamples of such materials include, but not limited to, buffers,diluents, filters, needles, syringes; carrier, package, container, vialand/or tube labels listing contents and/or instructions for use andpackage inserts with instructions for use. A set of instructions isoptionally included. In a further embodiment, a label is on orassociated with the container. In yet a further embodiment, a label ison a container when letters, numbers or other characters forming thelabel are attached, molded or etched into the container itself; a labelis associated with a container when it is present within a receptacle orcarrier that also holds the container, e.g., as a package insert. Inother embodiments a label is used to indicate that the contents are tobe used for a specific therapeutic application. In yet anotherembodiment, a label also indicates directions for use of the contents,such as in the methods described herein.

In certain embodiments, the pharmaceutical compositions are presented ina pack or dispenser device that contains one or more unit dosage formscontaining a compound provided herein. In another embodiment, the packfor example contains metal or plastic foil, such as a blister pack. In afurther embodiment, the pack or dispenser device is accompanied byinstructions for administration. In yet a further embodiment, the packor dispenser is also accompanied with a notice associated with thecontainer in form prescribed by a governmental agency regulating themanufacture, use, or sale of pharmaceuticals, which notice is reflectiveof approval by the agency of the form of the drug for human orveterinary administration. In another embodiment, such notice, forexample, is the labeling approved by the U.S. Food and DrugAdministration for prescription drugs, or the approved product insert.In yet another embodiment, compositions containing a compound providedherein formulated in a compatible pharmaceutical carrier are alsoprepared, placed in an appropriate container, and labeled for treatmentof an indicated condition.

EXAMPLES Example 1 Preparation of a Methotrexate/HyaluronidaseThermoreversible Gel Formulation

Quantity (mg/g of Ingredient formulation) Methylparaben 1.0 HPMC 10.0Poloxamer 407 180.0 TRIS HCl buffer (0.1 M) 808.0 Hyaluronidase 1.0Thimerosal 0.1

A 10-g batch of gel formulation containing 0.1% of hyaluronidase isprepared by suspending 1.80 g of Poloxamer 407 (BASF Corp.) in 5.00 g ofTRIS HCl buffer (0.1 M) and the components are mixed under agitationovernight at 4° C. to ensure complete dissolution. Thehydroxypropylmethylcellulose (100.0 mg), methylparaben (10 mg) andadditional TRIS HCl buffer (0.1 M) (3.08 g) are added and furtherstirring allowed until complete dissolution is observed. Methotrexate(10 mg) is added and mixed in order to solubilize. The mixture ismaintained below room temperature until use.

Example 2 Preparation of a Collagen Mucoadhesive, Thermoreversible GelFormulation

Quantity (mg/g of Ingredient formulation) Collagen 10.0 Methylparaben1.0 HPMC 10.0 Carbopol 934P 2.0 Poloxamer 407 180.0 TRIS HCl buffer (0.1M) 797.0 Thimerosal 0.1

A 10-g batch of a mucoadhesive, gel formulation containing 1.0% ofcollagen is prepared by suspending 20.0 mg of Carbopol 934P and 1.80 gof Poloxamer 407 (BASF Corp.) in 5.00 g of TRIS HCl buffer (0.1 M) andthe components are mixed under agitation overnight at 4° C. to ensurecomplete dissolution. The hydroxypropylmethylcellulose (100.0 mg),methylparaben (10 mg) and additional TRIS HCl buffer (0.1 M) (2.97 g)are added and further stirring allowed until complete dissolution isobserved. The mixture is maintained below room temperature until use.

Example 3 Preparation of a Thermoreversible Gel KCNQModulator/Hyaluronidase Formulation

Quantity (mg/g of Ingredient formulation) Retigabine 18.0 Hyaluronidase2.0 methylparaben 1.0 HPMC 10.0 Poloxamer 407 180.0 TRIS HCl buffer (0.1M) 789.0

A 10-g batch of gel formulation containing 1.8% of retigabine, 0.2%hyaluronidase is prepared by suspending 1.80 g of Poloxamer 407 (BASFCorp.) in 5.00 g of TRIS HCl buffer (0.1 M) and the components are mixedunder agitation overnight at 4° C. to ensure complete dissolution. Theretigabine (200.0 mg), hydroxypropylmethylcellulose (100.0 mg),methylparaben (10 mg) and additional TRIS HCl buffer (0.1 M) (2.89 g) isadded and further stirring allowed until complete dissolution isobserved. The mixture is maintained below room temperature until use.

Example 4 Preparation of a Hyaluronidase Mucoadhesive-Based Formulation

Quantity (mg/g of Ingredient formulation) Hyaluronidase 10.0 Sodiumcitrate 1.25 Sodium ascorbate 0.8 Paraffin oil 200 Trihydroxystearate 10Cetyl dimethicon copolyol 30 Water qs ad 1000 Phosphate buffer pH 7.4 qspH 7.4

The cream-type formulation is first prepared by gently mixing ahyaluronidase with a buffer. A second system is prepared by mixingparaffin oil, trihydroxystearate and cetyl dimethicon copolyol withwarming to 60° C. Upon cooling to room temperature, the lipid system ismixed with the aqueous phase for 30 minutes.

Example 5 Preparation of a Collagenase Mucoadhesive, ThermoreversibleGel Formulation

Quantity (mg/g of Ingredient formulation) Collagenase 10.0 Methylparaben1.0 Poloxamer 407 180.0 Carbopol 934P 2.0 TRIS HCl buffer (0.1 M) 316.0Thimerosal 0.1

The Carbopol 934P and Poloxamer 407 (BASF Corp.) is first suspended inthe TRIS HCl buffer (0.1 M) and the components are mixed under agitationovernight at 4° C. to ensure complete dissolution. The methylparaben isadded and further stirring allowed until complete dissolution isobserved. The collagenase is mixed in while maintaining stirring toproduce a 0.2% collagenase mucoadhesive, thermoreversible gelformulation. The mixture is maintained below room temperature until use.

Viscosity determinations of the pharmaceutical compositions describedherein are performed at room temperature and 37° C. and are made using aBrookfield (spindle and cup) viscometer at 20 rpm.

Example 6 Preparation of a Keratin Mucoadhesive-Based Formulation

Quantity (mg/g of Ingredient formulation) Keratin 100.0 Sodium citrate6.75 Sodium ascorbate 4.32 Paraffin oil 500.0 Trihydroxystearate 54.0Cetyl dimethicon copolyol 162.0 Water qs ad 1000 Phosphate buffer pH 7.4qs pH 7.4

The cream-type formulation is first prepared by gently mixing a keratinwith a buffer. A second system is prepared by mixing paraffin oil,trihydroxystearate and cetyl dimethicon copolyol with warming to 60° C.Upon cooling to room temperature, the lipid system is mixed with theaqueous phase for 30 minutes.

Example 7 Preparation of a Gel/Liposome Thyme Oil Formulation

Ingredient Quantity Thyme oil 20.0 mg/g Liposomes 15 umol/mlChitosan-Glycerophosphate 100.0 mg/g

The liposomes are prepared in the presence of the thyme oil by thereversed-phase evaporation method, where lipids in chloroform orchloroform-methanol (2:1, v/v) are deposited on the sides of a tube byevaporation of the organic solvent. The lipid film is redissolved indiethyl ether and the aqueous phase (pH 7.4 300 mOsm/kg) containing 20mM Hepes and 144 mM NaCl is added. The mixture is sonicated to obtain ahomogeneous emulsion, and then the organic solvent is removed undervacuum. The preparation is extruded to obtain the required liposome sizeand free components removed by size-exclusion chromatography using aSephadex G-50 column (Amersham Pharmacia Biotech, Uppsala, Sweden).

To prepare the chitosan-glycerophosphate formulation, a 5 ml solution ofacetic acid is titrated to a pH of about 4.0. The chitosan is added toachieve a pH of about 5.5. This solution is sterilized by filtration. A5 ml aqueous solution of glycerophosphate disodium is also prepared andsterilized. The two solutions are mixed and within 2 h at 37° C., andthe desired gel is formed. The chitosan-glycerophosphate solution isgently mixed with the liposomes at room temperature.

Example 8 Preparation of a Bisphosphonate Thermoreversible GelFormulation

Quantity (mg/g of Ingredient formulation) Alendronate sodium 10.0 Sodiumcitrate 1.25 Sodium ascorbate 0.8 Hyaluronidase PH20 10 Poloxamer 407 15Water qs ad 1000 Phosphate buffer pH 7.4 qs pH 7.4

The liquid formulation is prepared by mixing alendronate sodium andhyaluronidase PH20 with a buffer to form a first solution. A secondsystem is prepared by mixing poloxamer 407, sodium citrate, and sodiumascorbate in water with warming to 60° C. The first solution is added tothe second system and mixed well.

Example 9 Preparation of a Hyaluronidase Thermoreversible GelFormulation

Quantity (mg/g of Ingredient formulation) Hyaluronidase PH20 200 Sodiumchloride 10 Edetate disodium 1.2 Calcium chloride 0.5 Poloxamer 188 12Water qs ad 1000 Phosphate buffer pH 7.4 qs pH 7.4

The liquid formulation is first prepared by gently mixing PH20 with abuffer. A second system is prepared by mixing poloxamer 188, sodiumchloride, edetate disodium and calcium chloride in water with warming to60° C. The PH20 solution is added to the second system and mixed well.

Example 10 Preparation of a Bisphosphonate Mucoadhesive-BasedFormulation

Quantity (mg/g of Ingredient formulation) risedronate 10.0 Sodiumcitrate 1.25 Sodium ascorbate 0.8 Paraffin oil 200 Hydroxypropylmethylcellulose 10 Cetyl dimethicon copolyol 30 Water qs ad 1000Phosphate buffer pH 7.4 qs pH 7.4

The cream-type formulation is first prepared by gently mixingrisedronate with a buffer. A second system is prepared by mixingparaffin oil, hydroxypropyl methylcellulose and cetyl dimethiconcopolyol with warming to 60° C. Upon cooling to room temperature, thelipid system is mixed with the aqueous phase for 30 minutes.

Example 11 Preparation of a Parathyroid Hormone Mucoadhesive-BasedFormulation

Quantity (mg/g of Ingredient formulation) Parathyroid Hormone 100.0Sodium citrate 6.75 Sodium ascorbate 4.32 Paraffin oil 500.0Trihydroxystearate 54.0 Cetyl dimethicon copolyol 162.0 Water qs ad 1000Phosphate buffer pH 7.4 qs pH 7.4

The cream-type formulation is first prepared by gently mixing aparathyroid hormone with a buffer. A second system is prepared by mixingparaffin oil, trihydroxystearate and cetyl dimethicon copolyol withwarming to 60° C. Upon cooling to room temperature, the lipid system ismixed with the aqueous phase for 30 minutes.

Example 12 Preparation of a FUT-175 Thermoreversible Gel Formulation

Quantity (mg/g of Ingredient formulation) Methylparaben 3.0 HPMC 30.0Poloxamer 407 540.0 TRIS HCl buffer (0.1 M) 2424.0 FUT-175 3.0

A 10-g batch of gel formulation containing 0.1% of FUT-175 is preparedby suspending 1.80 g of Poloxamer 407 (BASF Corp.) in 5.00 g of TRIS HClbuffer (0.1 M) and the components are mixed under agitation overnight at4° C. to ensure complete dissolution. The hydroxypropylmethylcellulose(100.0 mg), methylparaben (10 mg) and additional TRIS HCl buffer (0.1 M)(3.08 g) are added and further stirring allowed until completedissolution is observed. The mixture is maintained below roomtemperature until use.

Example 13 Preparation of a TKIXc Mucoadhesive, Thermoreversible GelFormulation

Quantity (mg/g of Ingredient formulation) TKIXc 45.0 Methylparaben 4.5HPMC 45.0 Carbopol 934P 9.0 Poloxamer 407 810.0 TRIS HCl buffer (0.1 M)3586.5

A 10-g batch of a mucoadhesive, gel formulation containing 1.0% of TKIXcis prepared by suspending 20.0 mg of Carbopol 934P and 1.80 g ofPoloxamer 407 (BASF Corp.) in 5.00 g of TRIS HCl buffer (0.1 M) and thecomponents are mixed under agitation overnight at 4° C. to ensurecomplete dissolution. The hydroxypropylmethylcellulose (100.0 mg),methylparaben (10 mg) and additional TRIS HCl buffer (0.1 M) (2.97 g)are added and further stirring allowed until complete dissolution isobserved. The mixture is maintained below room temperature until use.

Example 14 Preparation of a TKIXc Mucoadhesive-Based Formulation

Quantity (mg/g of Ingredient formulation) TKIXc 25.0 Sodium citrate3.125 Sodium ascorbate 2.0 Paraffin oil 500.0 Trihydroxystearate 25.0Cetyl dimethicon copolyol 75.0 Water qs ad 1000 Phosphate buffer pH 7.4qs pH 7.4

The cream-type formulation is first prepared by gently mixing a TKIXcwith a buffer. A second system is prepared by mixing paraffin oil,trihydroxystearate and cetyl dimethicon copolyol with warming to 60° C.Upon cooling to room temperature, the lipid system is mixed with theaqueous phase for 30 minutes.

Example 15 Preparation of a Heparin Mucoadhesive, Thermoreversible GelFormulation

Quantity (mg/g of Ingredient formulation) Heparin 10.0 Methylparaben 1.0Poloxamer 407 180.0 Carbopol 934P 2.0 TRIS HCl buffer (0.1 M) 316.0Thimerosal 0.1

The Carbopol 934P and Poloxamer 407 (BASF Corp.) is first suspended inthe TRIS HCl buffer (0.1 M) and the components are mixed under agitationovernight at 4° C. to ensure complete dissolution. The methylparaben isadded and further stirring allowed until complete dissolution isobserved. The heparin is mixed in while maintaining stirring to producea 0.2% collagenase mucoadhesive, thermoreversible gel formulation. Themixture is maintained below room temperature until use.

Viscosity determinations of the pharmaceutical compositions describedherein are performed at room temperature and 37° C. and are made using aBrookfield (spindle and cup) viscometer at 20 rpm.

Example 16 Application of an Enhanced Viscosity Otic Agent Formulationonto the Round Window Membrane

A formulation according to Example 2 is prepared and loaded into 5 mlsiliconized glass syringes attached to a 15-gauge luer lock disposableneedle. Lidocaine is topically applied to the tympanic membrane, and asmall incision made to allow visualization into the middle ear cavity.The needle tip is guided into place over the round window membrane, andthe otic agent formulation applied directly onto the round-windowmembrane.

Example 17 Preparation of a Gel/Liposome sCR1-SLe^(x) Formulation

Ingredient Quantity sCR1-SLe^(x) 20.0 mg/g Liposomes 15 umol/mlChitosan-Glycerophosphate 100.0 mg/g

The liposomes are prepared in the presence of the sCR1-SLe^(x) by thereversed-phase evaporation method, where lipids in chloroform orchloroform-methanol (2:1, v/v) are deposited on the sides of a tube byevaporation of the organic solvent. The lipid film is redissolved indiethyl ether and the aqueous phase (pH 7.4 300 mOsm/kg) containing 20mM Hepes and 144 mM NaCl is added. The mixture is sonicated to obtain ahomogeneous emulsion, and then the organic solvent is removed undervacuum. The preparation is extruded to obtain the required liposome sizeand free components removed by size-exclusion chromatography using aSephadex G-50 column (Amersham Pharmacia Biotech, Uppsala, Sweden).

To prepare the chitosan-glycerophosphate formulation, a 5 ml solution ofacetic acid is titrated to a pH of about 4.0. The chitosan is added toachieve a pH of about 5.5. This solution is sterilized by filtration. A5 ml aqueous solution of glycerophosphate disodium is also prepared andsterilized. The two solutions are mixed and within 2 h at 37° C., andthe desired gel is formed. The chitosan-glycerophosphate solution isgently mixed with the liposomes at room temperature.

Example 18 Application of an Enhanced Viscosity Otic Agent Formulationonto the Round Window Membrane

A formulation according to example 2 is prepared and loaded into 5 mlsiliconized glass syringes attached to a 15-gauge luer lock disposableneedle. Lidocaine is topically applied to the tympanic membrane, and asmall incision made to allow visualization into the middle ear cavity.The needle tip is guided into place over the round window membrane, andthe otic agent formulation applied directly onto the round-windowmembrane.

Example 19 Effect of pH on Degradation Products for Autoclaved 17%Poloxamer 407NF/2% Otic Agent in PBS Buffer

A stock solution of a 17% poloxamer 407/2% otic agent is prepared bydissolving 351.4 mg of sodium chloride (Fisher Scientific), 302.1 mg ofsodium phosphate dibasic anhydrous (Fisher Scientific), 122.1 mg ofsodium phosphate monobasic anhydrous (Fisher Scientific) and anappropriate amount of an otic agent with 79.3 g of sterile filtered DIwater. The solution is cooled down in a ice chilled water bath and then17.05 g of poloxamer 407NF (SPECTRUM CHEMICALS) is sprinkled into thecold solution while mixing. The mixture is further mixed until thepoloxamer is completely dissolved. The pH for this solution is measured.

17% poloxamer 407/2% otic agent in PBS pH of 5.3. Take an aliquot(approximately 30 mL) of the above solution and adjust the pH to 5.3 bythe addition of 1 M HCl.

17% poloxamer 407/2% otic agent in PBS pH of 8.0. Take an aliquot(approximately 30 mL) of the above stock solution and adjust the pH to8.0 by the addition of 1 M NaOH.

A PBS buffer (pH 7.3) is prepared by dissolving 805.5 mg of sodiumchloride (Fisher Scientific), 606 mg of sodium phosphate dibasicanhydrous (Fisher Scientific), 247 mg of sodium phosphate monobasicanhydrous (Fisher Scientific), then QS to 200 g with sterile filtered DIwater.

A 2% solution of an otic agent in PBS pH 7.3 is prepared by dissolvingan appropriate amount of the otic agent in the PBS buffer and QS to 10 gwith PBS buffer.

One mL samples are individually placed in 3 mL screw cap glass vials(with rubber lining) and closed tightly. The vials are placed in aMarket Forge-sterilmatic autoclave (settings, slow liquids) andsterilized at 250° F. for 15 minutes. After the autoclave the samplesare left to cool down to room temperature and then placed inrefrigerator. The samples are homogenized by mixing the vials whilecold.

Appearance (e.g., discoloration and/or precipitation) is observed andrecorded. HPLC analysis is performed using an Agilent 1200 equipped witha Luna C18(2) 3 μm, 100 Å, 250×4.6 mm column) using a 30-80 acetonitrilegradient (1-10 min) of (water-acetonitrile mixture containing 0.05%TFA), for a total run of 15 minutes. Samples are diluted by taking 30 μLof sample and dissolved with 1.5 mL of a 1:1 acetonitrile water mixture.Purity of the otic agent in the autoclaved samples is recorded.

In general the composition should not have any individual impurity(e.g., degradation product of otic agent) of more than 2% and morepreferably not more than one percent. In addition, the compositionshould not precipitate during storage or change in color aftermanufacturing and storage.

Compositions comprising alprazolam, clonazepam, diazepam, or micronizeddiazepam, prepared according to the procedure in Example 6, are testedusing the above procedure to determine the effect of pH on degradationduring the autoclaving step.

Example 20 Effect of Autoclaving on the Release Profile and Viscosity ofa 17% Poloxamer 407NF/2% Otic Agent in PBS

An aliquot of the sample from example 6 (autoclaved and not autoclaved)is evaluated for release profile and viscosity measurement to evaluatethe impact of heat sterilization on the properties of the gel.

Dissolution is performed at 37° C. in snapwells (6.5 mm diameterpolycarbonate membrane with a pore size of 0.4 μm). 0.2 mL of gel isplaced into snapwell and left to harden, then 0.5 mL is placed intoreservoir and shaken using a Labline orbit shaker at 70 rpm. Samples aretaken every hour (0.1 mL withdrawn and replace with warm buffer).Samples are analyzed for poloxamer concentration by UV at 624 nm usingthe cobalt thiocyanate method, against an external calibration standardcurve. In brief, 20 μL of the sample is mixed with 1980 μL of a 15 mMcobalt thiocyanate solution and absorbance measured at 625 nm, using aEvolution 160 UV/Vis spectrophotometer (Thermo Scientific).

The released otic agent is fitted to the Korsmeyer-Peppas equation

$\frac{Q}{Q_{\alpha}} = {{kt}^{n} + b}$

where Q is the amount of otic agent released at time t, Q_(α) is theoverall released amount of otic agent, k is a release constant of thenth order, n is a dimensionless number related to the dissolutionmechanism and b is the axis intercept, characterizing the initial burstrelease mechanism wherein n=1 characterizes an erosion controlledmechanism. The mean dissolution time (MDT) is the sum of differentperiods of time the drug molecules stay in the matrix before release,divided by the total number of molecules and is calculated by:

${MDT} = \frac{{nk}^{{- 1}/n}}{n + 1}$

Viscosity measurements are performed using a Brookfield viscometerRVDV-II+P with a CPE-51 spindle rotated at 0.08 rpm (shear rate of 0.31s⁻¹), equipped with a water jacketed temperature control unit(temperature ramped from 15-34° C. at 1.6° C./min). Tgel is defined asthe inflection point of the curve where the increase in viscosity occursdue to the sol-gel transition.

Compositions comprising collagen, keratin, collagenase, or micronizedcollagen prepared according to the procedure in Example 6, are testedusing the procedure described above to determine Tgel.

Example 21 Effect of Addition of a Secondary Polymer on the DegradationProducts and Viscosity of a Composition Containing 2% Otic Agent and 17%Poloxamer 407NF after Heat Sterilization (Autoclaving)

Solution A. A solution of pH 7.0 comprising sodiumcarboxymethylcellulose (CMC) in PBS buffer is prepared by dissolving178.35 mg of sodium chloride (Fisher Scientific), 300.5 mg of sodiumphosphate dibasic anhydrous (Fisher Scientific), 126.6 mg of sodiumphosphate monobasic anhydrous (Fisher Scientific) dissolved with 78.4 ofsterile filtered DI water, then 1 g of Blanose 7M65 CMC (Hercules,viscosity of 5450cP @ 2%) is sprinkled into the buffer solution andheated to aid dissolution, and the solution is then cooled down.

A solution of pH 7.0 comprising 17% poloxamer 407NF/1% CMC/2% otic agentin PBS buffer is made by cooling down 8.1 g of solution A in a icechilled water bath and then adding an appropriate amount of an oticagent followed by mixing. 1.74 g of poloxamer 407NF (Spectrum Chemicals)is sprinkled into the cold solution while mixing. The mixture is furthermixed until all the poloxamer is completely dissolved.

Two mL of the above sample is placed in a 3 mL screw cap glass vial(with rubber lining) and closed tightly. The vial is placed in a MarketForge-sterilmatic autoclave (settings, slow liquids) and sterilized at250° F. for 25 minutes. After autoclaving the sample is left to cooldown to room temperature and then placed in refrigerator. The sample ishomogenized by mixing while the vials are cold.

Precipitation or discoloration are observed after autoclaving. HPLCanalysis is performed using an Agilent 1200 equipped with a Luna C18(2)3 μm, 100 Å, 250×4.6 mm column) using a 30-80 acetonitrile gradient(1-10 min) of (water-acetonitrile mixture containing 0.05% TFA), for atotal run of 15 minutes. Samples are diluted by taking 30 μL of sampleand dissolving with 1.5 mL of a 1:1 acetonitrile water mixture. Purityof the otic agent in the autoclaved samples is recorded.

Viscosity measurements are performed using a Brookfield viscometerRVDV-II+P with a CPE-51 spindle rotated at 0.08 rpm (shear rate of 0.31s⁻¹), equipped with a water jacketed temperature control unit(temperature ramped from 15-34° C. at 1.6° C./min). Tgel is defined asthe inflection point of the curve where the increase in viscosity occursdue to the sol-gel transition.

Dissolution is performed at 37° C. for the non-autoclaved sample insnapwells (6.5 mm diameter polycarbonate membrane with a pore size of0.4 μm), 0.2 mL of gel is placed into snapwell and left to harden, then0.5 mL is placed into reservoir and shaken using a Labline orbit shakerat 70 rpm. Samples are taken every hour (0.1 mL withdrawn and replacedwith warm buffer). Samples are analyzed for otic agent concentration byUV at 245 nm, against an external calibration standard curve.

Compositions comprising collagen, keratin, collagenase, or micronizedcollagen are tested using the above procedure to determine the effectaddition of a secondary polymer on the degradation products andviscosity of a composition containing 2% otic agent and 17% poloxamer407NF after heat sterilization (autoclaving).

Example 22 Effect of Buffer Type on the Degradation Products forCompositions Containing Poloxamer 407NF after Heat Sterilization(Autoclaving)

A TRIS buffer is made by dissolving 377.8 mg of sodium chloride (FisherScientific), and 602.9 mg of Tromethamine (Sigma Chemical Co.) then QSto 100 g with sterile filtered DI water, pH is adjusted to 7.4 with 1MHCl.

Stock Solution Containing 25% Poloxamer 407 Solution in Tris Buffer:

Weigh 45 g of TRIS buffer, chill in an ice chilled bath then sprinkleinto the buffer, while mixing, 15 g of poloxamer 407 NF (SpectrumChemicals). The mixture is further mixed until all the poloxamer iscompletely dissolved.

A series of compositions is prepared with the above stock solution. Anappropriate amount of otic agent (or salt or prodrug thereof) and/orotic agent as micronized/coated/liposomal particles (or salt or prodrugthereof) is used for all experiments.

Stock Solution (pH 7.3) Containing 25% Poloxamer 407 Solution in PBSBuffer:

PBS buffer is prepared by dissolving 704 mg of sodium chloride (FisherScientific), 601.2 mg of sodium phosphate dibasic anhydrous (FisherScientific), 242.7 mg of sodium phosphate monobasic anhydrous (FisherScientific) with 140.4 g of sterile filtered DI water. The solution iscooled down in an ice chilled water bath and then 50 g of poloxamer407NF (SPECTRUM CHEMICALS) is sprinkled into the cold solution whilemixing. The mixture is further mixed until the poloxamer is completelydissolved.

A series of compositions is prepared with the above stock solution. Anappropriate amount of otic agent (or salt or prodrug thereof) and/orotic agent as micronized/coated/liposomal particles (or salt or prodrugthereof) is used for all experiments.

Tables 2 and 3 list samples prepared using the procedures describedabove. An appropriate amount of otic agent is added to each sample toprovide a final concentration of 2% otic agent in the sample.

TABLE 2 Preparation of samples containing TRIS buffer 25% Stock SolutionTRIS Buffer Sample pH (g) (g) 20% P407/2% otic agent/TRIS 7.45 8.01 1.8218% P407/2% otic agent/TRIS 7.45 7.22 2.61 16% P407/2% otic agent/TRIS7.45 6.47 3.42 18% P4072% otic agent/TRIS 7.4 7.18 2.64  4% oticagent/TRIS 7.5 — 9.7  2% otic agent/TRIS 7.43 — 5  1% otic agent/TRIS7.35 — 5  2% otic agent/TRIS 7.4 — 4.9 (suspension)

TABLE 3 Preparation of samples containing PBS buffer (pH of 7.3) 25%Stock Solution Sample in PBS (g) PBS Buffer (g) 20% P407/2% otic agent/8.03 1.82 PBS 18% P407/2% otic agent/ 7.1  2.63 PBS 16% P407/2% oticagent/ 6.45 3.44 PBS 18% P407/2% otic agent/ — 2.63 PBS  2% oticagent/PBS — 4.9

One mL samples are individually placed in 3 mL screw cap glass vials(with rubber lining) and closed tightly. The vials are placed in aMarket Forge-sterilmatic autoclave (setting, slow liquids) andsterilized at 250° F. for 25 minutes. After the autoclaving the samplesare left to cool down to room temperature. The vials are placed in therefrigerator and mixed while cold to homogenize the samples.

HPLC analysis is performed using an Agilent 1200 equipped with a LunaC18(2) 3 μm, 100 Å, 250×4.6 mm column) using a 30-80 acetonitrilegradient (1-10 min) of (water-acetonitrile mixture containing 0.05%TFA), for a total run of 15 minutes. Samples are diluted by taking 30 μLof sample and dissolving with 1.5 mL of a 1:1 acetonitrile watermixture. Purity of the otic agent in the autoclaved samples is recorded.The stability of compositions in TRIS and PBS buffers is compared.

Viscosity measurements are performed using a Brookfield viscometerRVDV-II+P with a CPE-51 spindle rotated at 0.08 rpm (shear rate of 0.31s⁻¹), equipped with a water jacketed temperature control unit(temperature ramped from 15-34° C. at 1.6° C./min). Tgel is defined asthe inflection point of the curve where the increase in viscosity occursdue to the sol-gel transition. Only compositions that show no changeafter autoclaving are analyzed.

Compositions comprising Compositions comprising collagen, keratin,collagenase, or micronized collagen are tested using the above procedureto determine the effect addition of a secondary polymer on thedegradation products and viscosity of a composition containing 2% oticagent and 17% poloxamer 407NF after heat sterilization (autoclaving).Stability of compositions containing micronized otic agent is comparedto non-micronized otic agent composition counterparts.

Example 23 Pulsed Release Otic Compositions

Diazepam is used to prepare a pulsed release otic agent compositionusing the procedures described herein. A 17% poloxamer solution isprepared by dissolving 351.4 mg of sodium chloride (Fisher Scientific),302.1 mg of sodium phosphate dibasic anhydrous (Fisher Scientific),122.1 mg of sodium phosphate monobasic anhydrous (Fisher Scientific) andan appropriate amount of an otic agent with 79.3 g of sterile filteredDI water. The solution is cooled down in a ice chilled water bath andthen 17.05 g of poloxamer 407NF (SPECTRUM CHEMICALS) is sprinkled intothe cold solution while mixing. The mixture is further mixed until thepoloxamer is completely dissolved. The pH for this solution is measured.20% of the delivered dose of diazepam is solubilized in the 17%poloxamer solution with the aid of beta-cyclodextrins. The remaining 80%of the otic agent is then added to the mixture and the final compositionis prepared using any procedure described herein.

Pulsed release compositions comprising Compositions comprising collagen,keratin, collagenase, or micronized collagen prepared according to theprocedures and examples described herein, are tested using proceduresdescribed herein to determine pulse release profiles.

Example 24 Preparation of a 17% Poloxamer 407/2% Otic Agent/78 Ppm EvansBlue in PBS

A Stock solution of Evans Blue (5.9 mg/mL) in PBS buffer is prepared bydissolving 5.9 mg of Evans Blue (Sigma Chemical Co) with 1 mL of PBSbuffer. PBS buffer is prepared by dissolving 704 mg of sodium chloride(Fisher Scientific), 601.2 mg of sodium phosphate dibasic anhydrous(Fisher Scientific), 242.7 mg of sodium phosphate monobasic anhydrous(Fisher Scientific) with 140.4 g of sterile filtered DI water.

A Stock solution containing 25% Poloxamer 407 solution in PBS buffer (asin Example 9) is used in this study. An appropriate amount of an oticagent is added to the 25% Poloxamer 407 solution stock solution toprepare compositions comprising 2% of an otic agent (Table 4).

TABLE 4 Preparation of poloxamer 407 samples containing Evans Blue 25%P407in Evans Blue Sample ID PBS (g) PBS Buffer (g) Solution (μL) 17%P407/2% otic agent/ 13.6 6 265 EB 20% P407/2% otic agent/ 16.019 3.62265 EB 25% P407/2% otic agent/ 19.63 — 265 EB

Compositions comprising collagen, keratin, collagenase, or micronizedcollagen are prepared according to the procedures in Example 12 and aresterile filtered through 0.22 μm PVDF syringe filters (Milliporecorporation), and autoclaved.

The above compositions are dosed to guinea pigs in the middle ear byprocedures described herein and the ability of compositions to gel uponcontact and the location of the gel is identified after dosing and at 24hours after dosing.

Example 25 Terminal Sterilization of Poloxamer 407 Compositions with andwithout a Visualization Dye

17% poloxamer 407/2% otic agent/in phosphate buffer, pH 7.3: Dissolve709 mg of sodium chloride (Fisher Scientific), 742 mg of sodiumphosphate dibasic dehydrate USP (Fisher Scientific), 251.1 mg of sodiumphosphate monobasic monohydrate USP (Fisher Scientific) and anappropriate amount of an otic agent with 158.1 g of sterile filtered DIwater. The solution is cooled down in an ice chilled water bath and then34.13 g of poloxamer 407NF (Spectrum chemicals) is sprinkled into thecold solution while mixing. The mixture is further mixed until thepoloxamer is completely dissolved.

17% poloxamer 407/2% otic agent/59 ppm Evans blue in phosphate buffer:Take two mL of the 17% poloxamer 407/2% otic agent/in phosphate buffersolution and add 2 mL of a 5.9 mg/mL Evans blue (Sigma-Aldrich chemicalCo) solution in PBS buffer.

25% poloxamer 407/2% otic agent/in phosphate buffer: Dissolve 330.5 mgof sodium chloride (Fisher Scientific), 334.5 mg of sodium phosphatedibasic dehydrate USP (Fisher Scientific), 125.9 mg of sodium phosphatemonobasic monohydrate USP (Fisher Scientific) and an appropriate amountof an otic agent with 70.5 g of sterile filtered DI water.

The solution is cooled down in an ice chilled water bath and then 25.1 gof poloxamer 407NF (Spectrum chemicals) is sprinkled into the coldsolution while mixing. The mixture is further mixed until the poloxameris completely dissolved.

25% poloxamer 407/2% otic agent/59 ppm Evans blue in phosphate buffer:Take two mL of the 25% poloxamer 407/2% otic agent/in phosphate buffersolution and add 2 mL of a 5.9 mg/mL Evans blue (Sigma-Aldrich chemicalCo) solution in PBS buffer.

Place 2 mL of composition into a 2 mL glass vial (Wheaton serum glassvial) and seal with 13 mm butyl str (kimble stoppers) and crimp with a13 mm aluminum seal. The vials are placed in a Market Forge-sterilmaticautoclave (settings, slow liquids) and sterilized at 250° F. for 25minutes. After the autoclaving the samples are left to cool down to roomtemperature and then placed in refrigeration. The vials are placed inthe refrigerator and mixed while cold to homogenize the samples. Samplediscoloration or precipitation after autoclaving is recorded.

HPLC analysis is performed using an Agilent 1200 equipped with a LunaC18(2) 3 μm, 100 Å, 250×4.6 mm column) using a 30-95 methanol:acetatebuffer pH 4 gradient (1-6 min), then isocratic for 11 minutes, for atotal run of 22 minutes. Samples are diluted by taking 30 μL of sampleand dissolved with 0.97 mL of water. The main peaks are recorded in thetable below. Purity before autoclaving is always greater than 99% usingthis method.

Viscosity measurements are performed using a Brookfield viscometerRVDV-II+P with a CPE-51 spindle rotated at 0.08 rpm (shear rate of 0.31s⁻¹), equipped with a water jacketed temperature control unit(temperature ramped from 15-34° C. at 1.6° C./min). Tgel is defined asthe inflection point of the curve where the increase in viscosity occursdue to the sol-gel transition.

Compositions comprising collagen, keratin, collagenase, or micronizedcollagen prepared according to the procedure in Example 11, are testedusing the above procedures to determine stability of the compositions.

Example 26 In Vitro Comparison of Release Profile

Dissolution is performed at 37° C. in snapwells (6.5 mm diameterpolycarbonate membrane with a pore size of 0.4 μm), 0.2 mL of a gelcomposition described herein is placed into snapwell and left to harden,then 0.5 mL buffer is placed into reservoir and shaken using a Lablineorbit shaker at 70 rpm. Samples are taken every hour (0.1 mL withdrawnand replace with warm buffer). Samples are analyzed for otic agentconcentration by UV at 245 nm against an external calibration standardcurve. Pluronic concentration is analyzed at 624 nm using the cobaltthiocyanate method. Relative rank-order of mean dissolution time (MDT)as a function of % P407 is determined. A linear relationship between thecompositions mean dissolution time (MDT) and the P407 concentrationindicates that the otic agent is released due to the erosion of thepolymer gel (poloxamer) and not via diffusion. A non-linear relationshipindicates release of otic agent via a combination of diffusion and/orpolymer gel degradation.

Alternatively, samples are analyzed using the method described by LiXin-Yu paper [Acta Pharmaceutica Sinica 2008, 43(2):208-203] andRank-order of mean dissolution time (MDT) as a function of % P407 isdetermined.

Compositions comprising collagen, keratin, collagenase, or micronizedcollagen prepared according to the procedures described herein, aretested using the above procedure to determine the release profile of theotic agents.

Example 27 In Vitro Comparison of Gelation Temperature

The effect of Poloxamer 188 and an otic agent on the gelationtemperature and viscosity of Poloxamer 407 compositions is evaluatedwith the purpose of manipulating the gelation temperature.

A 25% Poloxamer 407 stock solution in PBS buffer (as in Example 9) and aPBS solution (as in Example 11) are used. Poloxamer 188NF from BASF isused. An appropriate amount of otic agent is added to the solutionsdescribed in Table 5 to provide a 2% composition of the otic agent.

TABLE 5 Preparation of samples containing poloxamer 407/poloxamer 18825% P407 Stock Poloxamer PBS Buffer Sample Solution (g) 188 (mg) (g) 16%P407/10% P188 3.207 501 1.3036 17% P407/10% P188 3.4089 500 1.1056 18%P407/10% P188 3.6156 502 0.9072 19% P407/10% P188 3.8183 500 0.7050 20%P407/10% P188 4.008 501 0.5032 20% P407/5% P188  4.01 256 0.770

Mean dissolution time, viscosity and gel temperature of the abovecompositions are measured using procedures described herein.

An equation is fitted to the data obtained and can be utilized toestimate the gelation temperature of F127/F68 mixtures (for 17-20% F127and 0-10% F68).

T _(gel)=−1.8(% F127)+1.3(% F68)+53

An equation is fitted to the data obtained and can be utilized toestimate the Mean Dissolution Time (hr) based on the gelationtemperature of F127/F68 mixtures (for 17-25% F127 and 0-10% F68), usingresults obtained in example 13 and 15.

MDT=−0.2(T _(gel))+8

Compositions comprising collagen, keratin, collagenase, or micronizedcollagen are prepared by addition of an appropriate amount of oticagents to the solutions described in Table 5. The gel temperature of thecompositions is determined using the procedure described above.

Example 28 Determination of Temperature Range for Sterile Filtration

The viscosity at low temperatures is measured to help guide thetemperature range at that the sterile filtration needs to occur toreduce the possibility of clogging.

Viscosity measurements are performed using a Brookfield viscometerRVDV-II+P with a CPE-40 spindle rotated at 1, 5 and 10 rpm (shear rateof 7.5, 37.5 and 75 s⁻¹), equipped with a water jacketed temperaturecontrol unit (temperature ramped from 10-25° C. at 1.6° C./min).

The Tgel of a 17% Pluronic P407 is determined as a function ofincreasing concentration of otic agent. The increase in Tgel for a 17%pluronic composition is estimated by:

ΔT _(gel)=0.93[% otic agent]

Compositions comprising collagen, keratin, collagenase, or micronizedcollagen prepared according to procedures described herein, are testedusing the above procedure to determine the temperature range for sterilefiltration. The effect of addition of increased amounts of otic agent onthe Tgel, and the apparent viscosity of the compositions is recorded.

Example 29 Determination of Manufacturing Conditions

TABLE 6 Viscosity of potential compositions at manufacturing/filtrationconditions. Apparent Viscosity^(a) (cP) Temperature @ Sample 5° C. belowTgel 20° C. 100 cP Placebo 52 cP @ 17° C. 120 cP   19° C. 17% P407/20otic 90 cP @ 18° C. 147 cP 18.5° C. agent 17% P407/6% otic 142 cP @ 22°C.  105 cP 19.7° C. agent ^(a)Viscosity measured at a shear rate of 37.5s⁻¹

An 8 liter batch of a 17% P407 placebo is manufactured to evaluate themanufacturing/filtration conditions. The placebo is manufactured byplacing 6.4 liters of DI water in a 3 gallon SS pressure vessel, andleft to cool down in the refrigerator overnight. The following morningthe tank was taken out (water temperature 5° C., RT 18° C.) and 48 g ofsodium chloride, 29.6 g of sodium phosphate dibasic dehydrate and 10 gof sodium phosphate monobasic monohydrate is added and dissolved with anoverhead mixer (IKA RW20 @ 1720 rpm). Half hour later, once the bufferis dissolved (solution temperature 8° C., RT 18° C.), 1.36 kg ofpoloxamer 407 NF (spectrum chemicals) is slowly sprinkled into thebuffer solution in a 15 minute interval (solution temperature 12° C., RT18° C.), then speed is increased to 2430 rpm. After an additional onehour mixing, mixing speed is reduced to 1062 rpm (complete dissolution).

The temperature of the room is maintained below 25° C. to retain thetemperature of the solution at below 19° C. The temperature of thesolution is maintained at below 19° C. up to 3 hours of the initiationof the manufacturing, without the need to chill/cool the container.

Three different Sartoscale (Sartorius Stedim) filters with a surfacearea of 17.3 cm² are evaluated at 20 psi and 14° C. of solution

1) Sartopore 2, 0.2 μm 5445307HS-FF (PES), flow rate of 16 mL/min

2) Sartobran P, 0.2 μm 5235307HS-FF (cellulose ester), flow rate of 12mL/min

3) Sartopore 2 XLI, 0.2 μm 5445307IS-FF (PES), flow rate of 15 mL/min

Sartopore 2 filter 5441307H4-SS is used, filtration is carried out atthe solution temperature using a 0.45, 0.2 μm Sartopore 2 150 sterilecapsule (Sartorius Stedim) with a surface area of 0.015 m² at a pressureof 16 psi. Flow rate is measured at approximately 100 mL/min at 16 psi,with no change in flow rate while the temperature is maintained in the6.5-14° C. range. Decreasing pressure and increasing temperature of thesolution causes a decrease in flow rate due to an increase in theviscosity of the solution. Discoloration of the solution is monitoredduring the process.

TABLE 7 Predicted filtration time for a 17% poloxamer 407 placebo at asolution temperature range of 6.5-14° C. using Sartopore 2, 0.2 μmfilters at a pressure of 16 psi of pressure. Estimated flow rate Time tofilter 8 L Filter Size (m²) (mL/min) (estimated) Sartopore 2, size 40.015 100 mL/min 80 min Sartopore 2, size 7 0.05 330 mL/min 24 minSartopore 2, size 8 0.1 670 mL/min 12 min

Viscosity, Tgel and UV/Vis absorption is check before filtrationevaluation. Pluronic UV/Vis spectra are obtained by a Evolution 160UV/Vis (Thermo Scientific). A peak in the range of 250-300 nm isattributed to BHT stabilizer present in the raw material (poloxamer).Table 8 lists physicochemical properties of the above solutions beforeand after filtration.

TABLE 8 Physicochemical properties of 17% poloxamer 407 placebo solutionbefore and after filtration Viscosity^(a) @ 19° C. Absorbance @ SampleTgel (° C.) (cP) 274 nm Before filtration 22 100 0.3181 After filtration22 100 0.3081 ^(a)Viscosity measured at a shear rate of 37.5 s⁻¹

The above process is applicable for manufacture of 17% P407compositions, and includes temperature analysis of the room conditions.Preferably, a maximum temperature of 19° C. reduces cost of cooling thecontainer during manufacturing. In some instances, a jacketed containeris used to further control the temperature of the solution to easemanufacturing concerns.

Example 30 In Vitro Release of Otic Agent from an Autoclaved MicronizedSample

17% poloxamer 407/1.5% otic agent in TRIS buffer: 250.8 mg of sodiumchloride (Fisher Scientific), and 302.4 mg of Tromethamine (SigmaChemical Co.) is dissolved in 39.3 g of sterile filtered DI water, pH isadjusted to 7.4 with 1M HCl. 4.9 g of the above solution is used and anappropriate amount of micronized otic agent is suspended and dispersedwell. 2 mL of the composition is transferred into a 2 mL glass vial(Wheaton serum glass vial) and sealed with 13 mm butyl styrene (kimblestoppers) and crimped with a 13 mm aluminum seal. The vial is placed ina Market Forge-sterilmatic autoclave (settings, slow liquids) andsterilized at 250° F. for 25 minutes. After the autoclaving the sampleis left to cool down to room temperature. The vial is placed in therefrigerator and mixed while cold to homogenize the sample. Samplediscoloration or precipitation after autoclaving is recorded.

Dissolution is performed at 37° C. in snapwells (6.5 mm diameterpolycarbonate membrane with a pore size of 0.4 μm), 0.2 mL of gel isplaced into snapwell and left to harden, then 0.5 mL PBS buffer isplaced into reservoir and shaken using a Labline orbit shaker at 70 rpm.Samples are taken every hour [0.1 mL withdrawn and replaced with warmPBS buffer containing 2% PEG-40 hydrogenated castor oil (BASF) toenhance otic agent solubility]. Samples are analyzed for otic agentconcentration by UV at 245 nm against an external calibration standardcurve. The release rate is compared to other compositions disclosedherein. MDT time is calculated for each sample.

Solubilization of otic agent in the 17% poloxamer system is evaluated bymeasuring the concentration of the otic agent in the supernatant aftercentrifuging samples at 15,000 rpm for 10 minutes using an eppendorfcentrifuge 5424. otic agent concentration in the supernatant is measuredby UV at 245 nm against an external calibration standard curve.

Compositions comprising collagen, keratin, collagenase, or micronizedcollagen prepared according to the procedures described herein, aretested using the above procedures to determine release rate of the oticagent from each composition.

Example 31 Release Rate or MDT and Viscosity of Composition ContainingSodium Carboxymethyl Cellulose

17% poloxamer 407/2% otic agent/1% CMC (Hercules Blanose 7M): A sodiumcarboxymethylcellulose (CMC) solution (pH 7.0) in PBS buffer is preparedby dissolving 205.6 mg of sodium chloride (Fisher Scientific), 372.1 mgof sodium phosphate dibasic dihydrate (Fisher Scientific), 106.2 mg ofsodium phosphate monobasic monohydrate (Fisher Scientific) in 78.1 g ofsterile filtered DI water. 1 g of Blanose 7M CMC (Hercules, viscosity of533cP @ 2%) is sprinkled into the buffer solution and heated to easesolution, solution is then cooled down and 17.08 g poloxamer 407NF(Spectrum Chemicals) is sprinkled into the cold solution while mixing. Acomposition comprising 17% poloxamer 407NF/1% CMC/2% otic agent in PBSbuffer is made adding/dissolving an appropriate amount of otic agent to9.8 g of the above solution, and mixing until all the otic agent iscompletely dissolved.

17% poloxamer 407/2% otic agent/0.5% CMC (Blanose 7M65): A sodiumcarboxymethylcellulose (CMC) solution (pH 7.2) in PBS buffer is preparedby dissolving 257 mg of sodium chloride (Fisher Scientific), 375 mg ofsodium phosphate dibasic dihydrate (Fisher Scientific), 108 mg of sodiumphosphate monobasic monohydrate (Fisher Scientific) in 78.7 g of sterilefiltered DI water. 0.502 g of Blanose 7M65 CMC (Hercules, viscosity of5450cP @ 2%) is sprinkled into the buffer solution and heated to easesolution, solution is then cooled down and 17.06 g poloxamer 407NF(Spectrum Chemicals) is sprinkled into the cold solution while mixing. A17% poloxamer 407NF/1% CMC/2% otic agent solution in PBS buffer is madeadding/dissolving an appropriate amount of otic agent to 9.8 g of theabove solution, and mixing until the otic agent is completely dissolved.

17% poloxamer 407/2% otic agent/0.5% CMC (Blanose 7H9): A sodiumcarboxymethylcellulose (CMC) solution (pH 7.3) in PBS buffer is preparedby dissolving 256.5 mg of sodium chloride (Fisher Scientific), 374 mg ofsodium phosphate dibasic dihydrate (Fisher Scientific), 107 mg of sodiumphosphate monobasic monohydrate (Fisher Scientific) in 78.6 g of sterilefiltered DI water, then 0.502 g of Blanose 7H9 CMC (Hercules, viscosityof 5600cP @ 1%) is sprinkled to the buffer solution and heated to easesolution, solution is then cooled down and 17.03 g poloxamer 407NF(Spectrum Chemicals) is sprinkled into the cold solution while mixing. A17% poloxamer 407NF/1% CMC/2% otic agent solution in PBS buffer is madeadding/dissolving an appropriate amount of otic agent to 9.8 of theabove solution, and mixing until the otic agent is completely dissolved.

Viscosity measurements are performed using a Brookfield viscometerRVDV-II+P with a CPE-40 spindle rotated at 0.08 rpm (shear rate of 0.6s⁻¹), equipped with a water jacketed temperature control unit(temperature ramped from 10-34° C. at 1.6° C./min). Tgel is defined asthe inflection point of the curve where the increase in viscosity occursdue to the sol-gel transition.

Dissolution is performed at 37° C. in snapwells (6.5 mm diameterpolycarbonate membrane with a pore size of 0.4 μm). 0.2 mL of gel isplaced into snapwell and left to harden, then 0.5 mL PBS buffer isplaced into reservoir and shaken using a Labline orbit shaker at 70 rpm.Samples are taken every hour, 0.1 mL withdrawn and replaced with warmPBS buffer. Samples are analyzed for otic agent concentration by UV at245 nm against an external calibration standard curve. MDT time iscalculated for each of the above compositions.

Compositions comprising collagen, keratin, collagenase, or micronizedcollagen prepared according to procedures described above, are testedusing the above procedures to determine relationship between releaserate and/or mean dissolution time and viscosity of compositioncontaining sodium carboxymethyl cellulose. Any correlation between themean dissolution time (MDT) and the apparent viscosity (measured at 2°C. below the gelation temperature) is recorded.

Example 32 Application of an Enhanced Viscosity Otic StructureModulating Agent or Innate Immune System Modulating Agent Compositiononto the Round Window Membrane

A composition according to Example 2 is prepared and loaded into 5 mlsiliconized glass syringes attached to a 15-gauge luer lock disposableneedle. Lidocaine is topically applied to the tympanic membrane, and asmall incision made to allow visualization into the middle ear cavity.The needle tip is guided into place over the round window membrane, andthe composition applied directly onto the round-window membrane.

Example 33 In Vivo Testing of Intratympanic Injection of a OticStructure Modulating Composition in a Guinea Pig

A cohort of 21 guinea pigs (Charles River, females weighing 200-300 g)is intratympanically injected with 50 μL of different P407-DSPcompositions described herein, containing 0 to 6% of an otic agent. Thegel elimination time course for each composition is determined. A fastergel elimination time course of a composition indicates lower meandissolution time (MDT). Thus the injection volume and the concentrationof an otic structure modulating agent or innate immune system modulatingagent in a composition are tested to determine optimal parameters forpreclinical and clinical studies.

Example 34 In Vivo Extended Release Kinetics

A cohort of 21 guinea pigs (Charles River, females weighing 200-300 g)is intratympanically injected with 50 μL 17% Pluronic F-127 compositionbuffered at 280 mOsm/kg and containing 1.5% to 4.5% of an otic structuremodulating agent or innate immune system modulating agent by weight ofthe composition. Animals are dosed on day 1. The release profile for thecompositions is determined based on analysis of the perilymph.

Example 35 Effect of Poloxamer Concentration and Active AgentConcentration on Release Kinetics

A series of compositions comprising varying concentrations of a gellingagent and micronized dexamethasone was prepared using proceduresdescribed above. The mean dissolution time (MDT) for each composition inTable 9 was determined using procedures described above.

TABLE 9 Preparation of poloxamer/otic agent compositions Sample pH MDT15.5% P407/1.5% dexamethasone/PBS 7.4 46 h   16% P407/1.5%dexamethasone/PBS 7.4 40 h   17% P407/1.5% dexamethasone/PBS 7.4 39 h15.5% P407/4.5% dexamethasone/PBS 7.4 >7 days   16% P407/4.5%dexamethasone/PBS 7.4 >7 days   17% P407/4.5% dexamethasone/PBS 7.4 >7days

The effect of gel strength and otic agent concentration on releasekinetics of an otic agent from the composition or device was determinedby measurement of the MDT for poloxamer, and measurement of MDT for oticagent. The half life of the otic agent and mean residence time of theotic agent was also determined for each formulation by measurement ofconcentration of the otic agent in the perilymph.

The apparent viscosity of each composition was measured as describedabove. A thermoreversible polymer gel concentration of about 15.5% in acomposition or device described above provided an apparent viscosity ofabout 270,000 cP. A thermoreversible polymer gel concentration of about16% in a composition or device described above provided an apparentviscosity of about 360,000 cP. A thermoreversible polymer gelconcentration of about 17% in a composition or device described aboveprovided an apparent viscosity of about 480,000 cP.

Compositions comprising collagen, keratin, collagenase, or micronizedcollagen, prepared according to the procedures described herein, aretested using the above procedure to determine release rate of the oticagent from each composition.

Example 36 Evaluation of Otic Agent Formulations in an Otitis MediaAnimal Model

Induction of Otitis Media

Healthy adult chinchillas weight 400 to 600 g with normal middle ears,ascertained by otoscopy and tympanometry are used for these studies.Eustachian tube obstruction is performed 24 hours before inoculation toprevent the inoculum from flowing out of the eustachian tube. Onemilliliter of type 3 S. pneumoniae strain at 4-h-log phase (containingapproximately 40 colony forming units (CFU)) is placed directly intoboth middle ear hypotympanic bullae of the chinhillas. Control mice areinoculated with one milliliter sterile PBS.

Treatment

S. pneumoniae inoculated and control mice are sorted into two groups(n=10 in each group). Otic agent formulation of Example 3 containinghyaluronidase is applied to the walls of the tympanic cavity of onegroup of animals. Control formulation containing no hyaluronidase isapplied to the second group. The hyaluronidase and control formulationsare reapplied three days after the initial application. The animals aresacrificed after the seventh day of treatment.

Analysis of Results

The amount of auris media ear fluid (MEF) is measured at 12, 24, 48, 72,96, 120, and 148 hours after pneumoccal inocualtion. Hearing analysis isalso performed at 12, 24, 48, 72, 96, 120, and 148 hours afterpneumoccal inocualtion. Finally, balance analysis is performed at 12,24, 48, 72, 96, 120, and 148 hours after pneumoccal inocualtion.

Example 37 Evaluation of Otic Agent Formulations in Tympanic MembranePerforation Animal Model

Otic agent formulations of Example 3 are tested in a tympanic membraneperforation animal model described in Amoils, C. P., et al. OtolaryngolHead Neck Surg. (1992), 106, 47-55. A cohort of 20 Chinchillas isdivided into control/untreated and test/treated groups for comparison ofthe effect of the otic agent formulation on tympanic membrane healing.The animals are subjected to thermal myringectomy followed by medialinfolding of tympanic membrane microflaps, resulting in permanentsubtotal chronic tympanic membrane perforations. The animals are keptunder observation for 6-8 weeks to ensure chronicity of tympanicmembrane perforations. Any animal demonstrating otitis externa, orotitis media are discarded. Any animal with spontaneous closure of theperforation is excluded from the study. At the end of the observationperiod, the animals are treated with the composition of Example 1 once aday for three weeks. The animals are examined by visual otologic examweekly for closure of the perforation. Progression of healing is alsorecorded.

Example 38 Evaluation of Otic Agent Formulations in an OtosclerosisAnimal Model

Otic agent formulations of Example 8 are tested in an otosclerosisanimal model described in ARO abstracts, 2008, abstract 352,Bisphosphonates Inhibit Bone Remodeling in the Otic Capsule ofOsteoprotegerin Deficient Mouse, an Animal Model of Otosclerosis. Threeweek old OPG knockout mice are treated with the formulation of Example 8(100 microgram/kg/day, 6 days, or 500 microgram/kg/day, 6 days) andsacrificed 9 and 18 weeks later. Prior to sacrifice, hearing isevaluated with auditory brainstem evoked response and distortion productotoacoustic emissions. Bone remodeling is evaluated as follows: temporalbones are processed for histological analysis and stained with Azure ortartrate resistant acid phosphatase stain, which evaluates osteoclastactivity.

Example 39 Clinical Trials of Hyaluronidase in Otitis Media withEffusion Patients

Study Objective

The primary objective of this study will be to assess the safety andefficacy of hyaluronidase compared with that of placebo in amelioratingotitis media with effusion symptoms in afflicted patients.

Methods

Study Design

This will be a phase 3, multicentre, double-blind, randomised,placebo-controlled, three-arm study comparing TKIXc (100 mg and 200 mg)to placebo in the treatment of otitis media with effusion symptoms.Approximately 150 subjects will be enrolled in this study, andrandomised (1:1) to 1 of 3 treatment groups based on a randomisationsequence prepared by sponsor. Each group will receive 200 mg controlledrelease hyaluronidase, 400 mg controlled release hyaluronidase, orcontrolled release placebo formulation.

After a 1-week baseline phase, patients from each group will berandomized to a 16 week double treatment period (8-week treatmentfollowed by an 8-week maintenance period). Primary efficacy will bemeasured as a percentage change in the amount of fluids (i.e. effusions)seen in the ears of the subjects.

Example 40 Clinical Trials of Bisphosphonates in Patients Suffering fromOtosclerosis

Study Objective

The primary objective of this study will be to assess the safety andefficacy of bisphosphonates compared with that of placebo in improvinghearing in afflicted patients.

Methods

Study Design

This will be a phase 3, multicentre, double-blind, randomised,placebo-controlled, three-arm study comparing the efficacy ofrisendronate (100 mg and 200 mg) to placebo in the treatment ofotosclerosis. Approximately 150 subjects will be enrolled in this study,and randomised (1:1) to 1 of 3 treatment groups based on a randomisationsequence prepared by sponsor. Each group will receive 200 mg ofrisendronate mucoadhesive formulation, 400 mg of risendronatemucoadhesive formulation, or mucoadhesive placebo formulation. Inclusioncriteria include otosclerosis where surgery is planned, air/bone gaplarger than 20 dB and normal middle ear status. Exclusion criteria arepregnancy, deafness on other ear or stapedectomy previously performed onear.

After a 1-week baseline phase, patients from each group will berandomized to a 16 week double treatment period (8-week treatmentfollowed by an 8-week maintenance period). Primary efficacy will bemeasured as a change in hearing thresholds.

Example 41 Evaluation of Otic Agent Formulations in an Otitis MediaAnimal Model

Induction of Otitis Media

Healthy adult chinchillas weight 400 to 600 g with normal middle ears,ascertained by otoscopy and tympanometry are used for these studies.Eustachian tube obstruction is performed 24 hours before inoculation toprevent the inoculum from flowing out of the eustachian tube. Onemilliliter of type 3 S. pneumoniae strain at 4-h-log phase (containingapproximately 40 colony forming units (CFU)) is placed directly intoboth middle ear hypotympanic bullae of the chinhillas. Control mice areinoculated with one milliliter sterile PBS.

Treatment

S. pneumoniae inoculated and control mice are sorted into two groups(n=10 in each group). Otic agent formulation of Example 3 is applied tothe walls of the tympanic cavity of one group of animals. A controlformulation containing no active agent is applied to the second group.The formulations are reapplied three days after the initial application.The animals are sacrificed after the seventh day of treatment.

Analysis of Results

The amount of auris media ear fluid (MEF) is measured at 12, 24, 48, 72,96, 120, and 148 hours after pneumoccal inocualtion. Hearing analysis isalso performed at 12, 24, 48, 72, 96, 120, and 148 hours afterpneumoccal inocualtion. Finally, balance analysis is performed at 12,24, 48, 72, 96, 120, and 148 hours after pneumoccal inocualtion.

Example 42 Clinical Trials of TKIXc in Otitis Media Patients

Study Objective

The primary objective of this study will be to assess the safety andefficacy of TKIXc compared with that of placebo in ameliorating otitismedia with effusion symptoms in afflicted patients.

Methods

Study Design

This will be a phase 3, multicentre, double-blind, randomised,placebo-controlled, three-arm study comparing TKIXc (100 mg and 200 mg)to placebo in the treatment of otitis media with effusion symptoms.Approximately 150 subjects will be enrolled in this study, andrandomised (1:1) to 1 of 3 treatment groups based on a randomisationsequence prepared by sponsor. Each group will receive 200 mg controlledrelease TKIXc, 400 mg controlled release TKIXc, or controlled releaseplacebo formulation.

After a 1-week baseline phase, patients from each group will berandomized to a 16 week double treatment period (8-week treatmentfollowed by an 8-week maintenance period). Primary efficacy will bemeasured as a percentage change in the amount of fluids (i.e. effusions)seen in the ears of the subjects.

While preferred embodiments of the present disclosure have been shownand described herein, such embodiments are provided by way of exampleonly. Various alternatives to the embodiments described herein areoptionally employed in practicing the inventions. It is intended thatthe following claims define the scope of the invention and that methodsand structures within the scope of these claims and their equivalents becovered thereby.

1. A pharmaceutical composition or device, comprising: a therapeuticallyeffective amount of a otic structure degrading agent havingsubstantially low degradation products; and wherein the composition ordevice comprises two or more characteristics selected from: (i) betweenabout 0.1% to about 10% by weight of the otic structure degrading agent,or pharmaceutically acceptable prodrug or salt thereof; (ii) betweenabout 14% to about 21% by weight of a polyoxyethylene-polyoxypropylenetriblock copolymer of general formula E106 P70 E106; (iii) sterilewater, q.s., buffered to provide a pH between about 5.5 and about 8.0;(iv) multiparticulate otic structure degrading agent; (v) a gelationtemperature between about 19° C. to about 42° C.; (vi) less than about50 colony forming units (cfu) of microbiological agents per gram ofcomposition; (vii) less than about 5 endotoxin units (EU) per kg of bodyweight of a subject; (viii) a mean dissolution time of about 30 hoursfor the otic structure degrading agent; and (ix) an apparent viscosityof about 100,000 cP to about 500,000 cP.
 2. The pharmaceuticalcomposition or device of claim 1, wherein the composition or devicecomprises: (i) between about 0.1% to about 10% by weight of the oticstructure degrading agent, or pharmaceutically acceptable prodrug orsalt thereof; (ii) between about 14% to about 21% by weight of apolyoxyethylene-polyoxypropylene triblock copolymer of general formulaE106 P70 E106; (iii) multiparticulate the otic structure degradingagent; and (iv) a gelation temperature between about 19° C. to about 42°C.
 3. The pharmaceutical composition or device of claim 1 wherein thecomposition or device provides a practical osmolarity between about 200and 400 mOsm/L.
 4. The pharmaceutical composition or device of claim 1,wherein the otic structure degrading agent is released for a period ofat least 3 days.
 5. The pharmaceutical composition or device of claim 1,wherein the pharmaceutical composition is an auris-acceptablethermoreversible gel.
 6. The pharmaceutical composition or device ofclaim 1, further comprising a dye.
 7. The pharmaceutical composition ordevice of claim 1, wherein the otic structure degrading agent is analcohol, an alkanol, an essential oil, a fatty acid, a glycol,laurocapram, a pyrrolidone, a sulfoxide, a surfactant, an enzyme, or acombination thereof. In some embodiments, the enzyme is a protease, aglycosidase, protease, a glycosidase, an actinase, a caseinase, achondroitinase, a collagenase, a dermatanase, an elastase, a gelatinase,a heparanase, a hyaluronidase, a keratinase, a lipase, ametalloproteinase (e.g. matrix metalloproteinase), a staphylokinase, astreptokinase, chymotrypsin, endopeptidase V8, trypsin, thermolysin,pepsin, plasmin, or combinations thereof.
 8. The pharmaceuticalcomposition or device of claim 1, wherein the otic structure degradingagent comprises multiparticulates.
 9. The pharmaceutical composition ordevice of claim 1, wherein the otic structure degrading agent isessentially in the form of micronized particles.
 10. The pharmaceuticalcomposition or device of claim 1, wherein the pH of the composition ordevice is between about 6.0 to about 7.6.
 11. The pharmaceuticalcomposition or device of claim 1, wherein the otic disease or conditionis otitis externa, otitis media, mastoiditis, sensorineural hearingloss, ototoxicity, endolymphatic hydrops, labyrinthitis, Meniere'sdisease, Meniere's syndrome, microvascular compression syndrome,vestibular neuronitis, acoustic trauma, presbycusis, cholesteatoma,otosclerosis, Scheibe syndrome, Mondini-Michelle syndrome, Waardenburg'ssyndrome, Michel syndrome, Alexander's ear deformity, hypertelorism,Jervell-Lange Nielson syndrome, Refsum's syndrome, Usher's syndrome, orcombinations thereof.
 12. A method of treating an otic disease orcondition characterized by excess otic structures comprisingadministering to an individual in need thereof an intratympaniccomposition or device comprising: a therapeutically effective amount ofan otic structure degrading agent having substantially low degradationproducts; and wherein the composition or device comprises two or morecharacteristics selected from: (i) between about 0.1% to about 10% byweight of the otic structure degrading agent, or pharmaceuticallyacceptable prodrug or salt thereof; (ii) between about 14% to about 21%by weight of a polyoxyethylene-polyoxypropylene triblock copolymer ofgeneral formula E106 P70 E106; (iii) sterile water, q.s., buffered toprovide a pH between about 5.5 and about 8.0; (iv) multiparticulate oticstructure degrading agent; (v) a gelation temperature between about 19°C. to about 42° C.; (vi) less than about 50 colony forming units (cfu)of microbiological agents per gram of composition, and (vii) less thanabout 5 endotoxin units (EU) per kg of body weight of a subject; (viii)a mean dissolution time of about 30 hours for the otic structuredegrading agent; and (ix) an apparent viscosity of about 100,000 cP toabout 500,000 cP.
 13. The method of claim 12, wherein the otic structuredegrading agent is released from the composition for a period of atleast 3 days.
 14. The method of claim 12, wherein the otic structuredegrading agent is essentially in the form of micronized particles. 15.The method of claim 12, wherein the otic structure degrading agentdegrades bone.
 16. The method of claim 12, wherein the otic structuredegrading agent degrades a neuron.
 17. The method of claim 12, whereinthe otic structure degrading agent degrades a membrane.
 18. The methodof claim 12, wherein the otic structure degrading agent degrades liquorpuris.
 19. The method of claim 12, wherein the otic structure degradingagent degrades endolymph or perilymph.